Background
Methods
Search strategy
Study selection
Intervention | Reason for exclusion |
---|---|
Barrier wipes that offer protection to the skin in the perineum | Although no water is used, these products are not used for the full body wash. Instead, these products offer protection to vulnerable skin. |
Antibacterial wipes, such as CHG (Chlorhexidine Gluconate) wipes | Although no water is used, these products are not used for the full body wash but for killing bacteria on the skin and thereby disinfecting the skin. Some studies were found in which CHG wipes were compared to washing without water products. These studies did not include washing with water in the comparison or were not a controlled trial and therefore were excluded. |
Original bag bath concept | When the original bag bath concept is used, non-disposable washcloths are put in a bag together with a no-rinse lotion diluted in water. Therefore, water still needs to be used to dilute the no-rinse solution. Furthermore, it is not a disposable solution. |
No-rinse sprays and cleansing lotions | Although no water is used, these products are not prepacked so that one package includes the materials needed for the full body wash. Separate wipes are still needed and therefore it is not an all-in-one solution as described in our definition of washing without water. |
Study screening and data extraction
Methodological quality
Items | Gillis et al. (2015) [26] | van Achterberg et al. (2015) [25] | Schoonhoven et al. (2015) [2] | Nøddeskou et al. (2015) [28] | Larson et al. (2004) [27] | Sheppard & Brenner (2000) [29] |
---|---|---|---|---|---|---|
Reporting | ||||||
1. Is the hypothesis/aim/objective of the study clearly described?a
Yes = 1, No = 0
| 1 | 1 | 1 | 1 | 1 | 1 |
2. Are the main outcomes to be measured clearly described in the introduction or methods section?
Yes = 1, No = 0
| 1 | 1 | 1 | 1 | 1 | 1 |
3. Are the characteristics of the patients included in the study clearly described?
Yes = 1, No = 0
| 1 | 1 | 1 | 1 | 1 | 1 |
4. Are the interventions of interest clearly described?
Yes = 1, No = 0
| 1 | 1 | 1 | 1 | 1 | 1 |
5. Are the distributions of principal confounders in each group of subjects to be compared clearly described?b
Yes = 1, No = 0
| 1 | 1 | 1 | 0 | 0 | 0 |
6. Are the main findings of the study clearly described?
Yes = 1, No = 0
| 1 | 1 | 1 | 0 | 1 | 1 |
7. Does the study provide estimates of the random variability in the data for the main outcomes?
Yes = 1, No = 0
| 1 | 1 | 1 | 1 | 1 | 1 |
8. Have all important adverse events that may be a consequence of the intervention been reported?
Yes = 1, No = 0
| 1 | 1 | 1 | 0 | 0 | 1 |
9. Have the characteristics of patients lost to follow-up been described?
Yes = 1, No = 0
| 1 | 0 | 0 | 0 | 0 | 0 |
10. Have actual probability values been reported for the main outcomes except where the probability is less than 0.001?
Yes = 1, No = 0
| 1 | 1 | 1 | 0 | 1 | 1 |
External validity | ||||||
11. Were the subjects asked to participate in the study representative of the entire population from which they were recruited?
Yes = 1, No = 0, Unable to determine = 0
| 1 | 1 | 1 | 0 | 0 | 0 |
12. Were those subjects who were prepared to participate, representative of the entire population from which they were recruited?
Yes = 1, No = 0, Unable to determine = 0
| 0 | 0 | 0 | 0 | 1 | 0 |
13. Were the staff, places, and facilities where the patients were treated representative of the treatment the majority of patients receive?
Yes = 1, No = 0, Unable to determine = 0
| 1 | 1 | 1 | 1 | 1 | 0 |
Internal validity – bias | ||||||
14. If any of the results of the study were based on “data dredging”, was this made clear?
Yes = 1, No = 0, Unable to determine = 0
| 0 | 1 | 1 | 1 | 0 | 0 |
15. Is the time period between the intervention and outcome the same for cases and controls?
Yes = 1, No = 0, Unable to determine = 0
| 1 | 1 | 1 | 1 | 1 | 1 |
16. Were the statistical tests used to assess the main outcomes appropriate?a
Yes = 1, No = 0, Unable to determine = 0
| 1 | 1 | 1 | 0 | 0 | 0 |
17. Was compliance with the intervention reliable?
Yes = 1, No = 0, Unable to determine = 0
| 0 | 1 | 1 | 1 | 1 | 0 |
18. Were the main outcome measures used accurate?
Yes = 1, No = 0, Unable to determine = 0
| 1 | 1 | 1 | 0 | 0 | 0 |
Internal validity – confounding (selection bias) | ||||||
19. Were patients in different intervention groups or were the cases and controls recruited from the same population?
Yes = 1, No = 0, Unable to determine = 0
| 1 | 1 | 1 | 1 | 1 | 1 |
20. Were the study subjects in different intervention groups or were the cases and controls recruited from the same population?
Yes = 1, No = 0, Unable to determine = 0
| 1 | 0 | 0 | 1 | 1 | 1 |
21. Were study subjects randomized to intervention groups?a
Yes = 1, No = 0, Unable to determine = 0
| 1 | 1 | 1 | 1 | 0 | 0 |
22. Was the randomized intervention assignment concealed from both patients and health care staff until recruitment was complete and irrevocable?
Yes = 1, No = 0, Unable to determine = 0
| 0 | 0 | 0 | 1 | 0 | 0 |
23. Was there adequate adjustment for confounding in the analyses from which the main findings were drawn?a
Yes = 1, No = 0, Unable to determine = 0
| 1 | 1 | 1 | 1 | 0 | 1 |
24. Were losses of patients to follow-up taken into account?
Yes = 1, No = 0, Unable to determine = 0
| 1 | 1 | 1 | 0 | 0 | 0 |
Power | ||||||
25. Did the study have sufficient power to detect a clinically important effect where the probability value for a difference being due to chance is less than 5%?ab
Yes = 1, No = 0
| 0 | 1 | 1 | 0 | 0 | 0 |
Total quality score | 20/25 | 21/25 | 21/25 | 14/25 | 13/25 | 12/25 |
Important quality items met | 4/5 | 5/5 | 5/5 | 3/5 | 1/5 | 2/5 |
Excluded original items for this study: • Was an attempt made to blind study subjects to the intervention they have received? • Was an attempt made to blind those measuring the main outcomes of the intervention? Reason for exclusion: it is practically impossible to blind study subjects and those who measure outcomes for the washing without water intervention. |
Data synthesis and analysis
Results
Search results
Study characteristics and quality
Author, year and country | Study design | Setting and sample population at baseline | Study duration |
---|---|---|---|
Gillis et al. (2015) [26] Belgium | Cluster controlled trial | Institutionalized long-term care 6 wards in 2 nursing homes 163 Residents with an average age of 84.9 years | 12 weeks |
van Achterberg et al. (2015) [25] The Netherlands | Cluster controlled trial | See Schoonhoven et al. (2015) [2] for setting and sample as the same dataset was used | 6 weeks |
Schoonhoven et al. (2015) [2] The Netherlands | Cluster controlled trial | Institutionalized long-term care 56 wards in 22 nursing homes 500 Residents: 61.6% Were diagnosed with dementia; average age of 82.4 years 275 Nurses | 6 weeks |
Nøddeskou et al. (2015) [28] Denmark | Randomized controlled cross- over trial | One hospital 65 Patients with an average age of 73 years 6 Nurses | 2 days |
Larson et al. (2004) [27] United States | Cross-over trial | Hospital – Three intensive care units of one hospital 47 Patients with an average age of 60.7 years 40 Nurses | 2 days |
Sheppard & Brenner (2000) [29] United States | Controlled time series trial | Institutionalized long-term care One nursing home 35 Residents: 56.25% Were cognitively impaired; average age of 85.17 years 11 Nurses | 6 weeks |
Study | Washing without water outcome | Sample population at end of study | Results |
---|---|---|---|
Gillis et al. (2015) [26] | Skin hydration (stratum corneum) at the leg, hand, and cheek | 150 Residents in pre-test and post-test stages (108 in the intervention group and 42 in the control group) | The post minus pre skin hydration scores were higher for the intervention group (washing without water) compared to the control group (traditional bed bath) at the cheek (p = 0.02) showing a higher increase in skin hydration for this skin site in the intervention group. |
van Achterberg et al. (2015) [25] | Bathing completeness | 450 Residents (257 in the intervention group and 193 in the control group) | Bathing completeness was more often found in the intervention group (washing without water) (p < 0.0001). When all body parts were cleaned, bathing was considered complete. |
Schoonhoven et al. (2015) [2] | Any skin abnormalities | 450 Residents (257 in the intervention group and 193 in the control group) | There is a difference in prevalence of any skin abnormalities over time (p = 0.04). The number of skin abnormalities decreased in the intervention group (washing without water) and increased in the control group (traditional bed bath). Any skin abnormalities included bright red discoloration, erythema, white, green or yellow discoloration of the wound bed, atrophic and shiny skin, satellite lesions and kissing lesions, fissures, erosions, or ulcerations on the buttocks, eyes, neck, armpits, elbows, sub-mammary region, umbilicus, abdomen, groins, anal cleft, or the skin between the toes. |
Significant skin lesions | 450 Residents (257 in the intervention group and 193 in the control group) | There is no difference in the prevalence of significant skin lesions over time between the intervention group and the control group (p = 0.82). If the skin on the buttocks, or in any of the skin folds in the sub-mammary region, abdomen, groins, or the anal cleft was not intact, the severity of the skin damage was considered to be significant. | |
Nurse satisfaction | 275 Nurses | Nurses gave an average grade of 7.5 (out of 10) for washing without water with a standard deviation of 1.2. 61% Of the nurses would replace water and soap bed baths with washing without water. | |
Resident satisfaction | 55 Residents | Residents gave an average grade of 7.1 (out of 10) for washing without water with a standard deviation of 2.0. 94% Thought washing without water cleaned the skin sufficient or good and 83% felt at least sufficiently fresh after being washed with washing without water. 61% Would permanently replace water and soap bed baths with washing without water. | |
Resistance during bathing | 450 Residents (257 in the intervention group and 193 in the control group) | There is no treatment by time interaction (p = 0.713). Resistance is observed by nurses and present if the resident: wards the nurse off, avoids the nurse’s touch, is restless, turns away, struggles with the nurse, or protests verbally. | |
Costs | 206 Observations of traditional baths and 272 observations of washing without water | There is no difference in costs at a confidence interval of 0.95. The total average costs over a time period of 6 weeks was €218,30 for washing without water and €232,20 for the traditional bed bath. The costs related to the nursing time needed to clean up after a bed bath were excluded from the calculation. | |
Nøddeskou et al. (2015) [28] | Nurse satisfaction | Preferences of 6 nurses for 54 individual bed baths | Nurses had a preference for washing without water compared to the traditional bed bath (p < 0.01). |
Costs | 58 Observations of traditional baths and 58 observations of washing without water | The average total costs of a washing without water bed bath in Danish Krone was 106.25 (11.84 material costs and 94.41 costs related to the salary of the nurse) compared to 126.96 for the traditional bed bath (11.87 material costs and 115.09 costs related to the salary of the nurse). Costs related to the use of machinery and electricity were excluded from the calculation. | |
Time of a bed bath | 58 Observations of traditional baths and 58 observations of washing without water | Less time was used during all stages of the bed bath (preparation, the bath itself, and cleaning up) and in total when washing without water was used compared to the traditional bed bath (p < 0.001 for all). | |
Quality score | 58 Observations of traditional baths and 58 observations of washing without water | Eight quality factors of the bed bath were checked and rated on a Likert scale from 1 to 10. The quality factors included (1) gathering bathing equipment, (2) wearing gloves, (3) explaining procedure to patient, (4) checking patients’ well-being, (5) ensuring patients’ privacy, (6) avoiding recontamination of patients’ skin, (7) cleaning all body surfaces, and (8) disposing equipment without environmental contamination, The mean total quality score for washing without water was 8 (out of 10) compared to a mean quality score of 7.9 (out of 10) for the traditional bed bath. | |
Larson et al. (2004) [27] | Reduction in microbial counts from the umbilicus | 29 Paired observations | There was no difference in the total bacterial counts between washing without water and the traditional bed bath (p = 0.47) after the bed bath, although the number of microbial counts increased in the washing without water group (p = 0.04). |
Reduction in microbial counts from the groin | 33 Paired observations | There was no difference in the total bacterial counts between washing without water and the traditional bed bath after the bed bath (p = 0.78). | |
Reduction in microbial counts of gram-negative bacteria from the groin | 33 Paired observations | There was no difference in the total bacterial counts between washing without water and the traditional bed bath (p = 0.22) after the bed bath, although the number of gram-negative bacteria counts decreased in the traditional bed bath group (p = 0.04). | |
Nurse satisfaction | 40 Nurses | Nurses preferred washing without water over the traditional bed bath on the items related to convenience, time-consumption, patient comfort, required supplies, and overall preference (p < 0.001 for all). The only item for which no preference was expressed was about which bath type is more likely to clean and moisturize the skin (p = 0.20). | |
Costs | 44 Observations of traditional baths and 44 observations of washing without water | The total average costs were $18.15 for washing without water compared to $19.87 for the traditional bed bath. Costs related to the use of water, heating and sewage (in case of the traditional bed bath) were excluded from the calculation. | |
Time of a bed bath | 43 Observations of traditional baths and 43 observations of washing without water | The mean bath time was 12.8 min for washing without water compared to 14.4 min for the traditional bed bath. The total time did not differ between the two types of bed baths (p = 0.08). The time needed for the preparation of the bed bath and for cleaning up after the bed bath were excluded from the calculation. Instead, nurses were asked to estimate the time needed to prepare a bed bath. Nurses (n = 40) estimated that this would take significantly less time when a washing without water product is used. | |
Quality score | 43 Observations of traditional baths and 43 observations of washing without water | The total quality score was 5.88 for washing without water compared to 5.51 for the traditional bed bath (p = 0.25). The quality of the bed bath was assessed by checking eight quality items. The quality items included (1) gathering bathing equipment, (2) wearing gloves, (3) explaining procedure to patient, (4) checking patients’ comfort and safety, (5) ensuring patients’ privacy, (6) avoiding recontamination of patients’ skin, (7) cleaning all body surfaces, and (8) disposing equipment without environmental contamination, The bed bath received a score of one point for each item met, resulting in a maximum score of 8. | |
Sheppard and Brenner (2000) [29] | Skin dryness | 30 Residents (16 in the intervention group and 14 in the control group) | The total skin condition differed between the two types of bed baths (p < 0.001). The total mean scores were stable in the control group (traditional bed bath) and improved over time in the intervention group (washing without water). More specifically, there was a difference between the groups in flaking (p < 0.001) and scaling (p = 0.001). |
Nurse satisfaction | 11 Nurses | 91% Of the nurses (strongly) agreed that washing without water was easy to administer and that residents were satisfied with this type of bed bath. 73% Thought washing without water was better for the skin of the resident compared to the traditional bed bath. 70% Thought the resident’s skin was clean after the bed bath with washing without water. 73% Indicated that washing without water was a worthy alternative for the traditional bed bath. | |
Resident satisfaction | 7 Residents of the intervention group (washing without water) | All (strongly) agreed that the product was easy to use and all liked the bathing technique. 86% Felt clean and indicated they had a softer skin after the bed bath with washing without water. 71% Indicated washing without water was a worthy alternative for the traditional bed bath. |