Improving efficiency, reducing

infection, and enhancing experience

Judith Massa

Abstract

For health professionals to make an informed choice and tailor each

bed bath to the individual needs of the patient, they must firstly
understand the different bed bath options available, their impact on
skin integrity, and any associated risks they may pose to the patient
in terms of cross-infection. Only with this knowledge can health
professionals determine the appropriate form and frequency of the bed
bath. Specialist wipes offer significant improvements in skin care and
a reduced risk of cross-infection, compared with the traditional soap
and water bed bath. Use of these wipes also improves the efficiency of
the process, which links to the Productive Ward Initiative and results in
clinical staff (i.e. nursing staff, healthcare assistants) having more time
available to undertake additional patient care activities. This product
focus highlights the benefits of moving to a wipe-based bed bath
method, and the significant efficiency savings that can be realized
as a result.
Key words: Bed bath n Skin integrity n Cross-infection
n Efficiency savings n Patient experience

aintaining levels of good personal hygiene

is essential for all patients during their stay
in hospital. For dependent patients who are
unable to make it to a bathroom, the bed
bath offers an alternative way to stay clean and fresh during
a hospital stay. The bed bath is a time-consuming and
labour-intensive process; however, by using the appropriate
products in the correct way, a carefully performed bed
bath will provide a number of benefits to the dependent
patient. Furthermore, the contact time with the patient for
that period of time is often therapeutically desirableboth
physically and psychologically.
The bed bath removes both organic matter and potentially
harmful microorganisms from the skin surface. A carefully
performed bed bath will stimulate tissue, muscles and blood
flow (Timby, 2009), while enabling the health professional to
perform a full skin inspection and test the patients range of
movement (Bryant and Rolstad, 2001).
A bed bath also helps with the control of body odour,
enhances the overall wellbeing of the patient (Bryant and

1408

Rolstad, 2001), and improves the patients own selfimage

(Timby, 2009). A bed bath refreshes the patient and can
help him/her to relax while providing positive sensory
stimulation (Bryant and Rolstad, 2001)again, both physical
and psychological.
As well as maintaining patient hygiene, the bed bath can
also have a significant impact on skin integrity. The skin is a
complex, self-repairing structure which performs a number
of key functions (Table 1). It is organized into three distinct
layers; the epidermis, the dermis and the subcutaneous layer
(Figure1).
The structure and function of the skin can be compromised
by factors such as ageing, dryness, bathing technique, activities
of daily living, and soaps (Bryant and Rolstad, 2001).
Therefore, depending on the form, frequency, products used,
protocol and skill of the clinical staff performing the bed
bath, it can either offer significant benefits to the patient or
expose them to some considerable risks.

Bed bath methods and options

There are essentially two bed bath options available for
todays health professional (Figure 2). Option one is the

Table 1. Key functions of the skin

Protection
An intact stratum corneum, acid pH and normal skin flora
form an effective, waterrepellent, physical barrier typically
hostile to pathogenic microbes. Skin also prevents chemicals
and foreign material entering the body.
Thermoregulation
Sweat evaporates from the skin to cool the body and skin.
Blood-flow can be controlled to regulate the amount of heat
lost through the skin.
Sensation
Skin contains sensory receptors for heat, cold, touch, pressure
and pain, which enable instinctive responses to potentially
harmful environmental stimuli.
Synthesis
When exposed to sunlight, skin synthesizes vitamin D.

Judith Massa is Clinical Procurement Specialist, Musgrove Park

Hospital, Taunton, Somerset

Excretion
Small amounts of urea and salts are excreted through
perspiration.

Accepted for publication: November 2010

From: Carola et al (1992)

British Journal of Nursing, 2010, Vol 19, No 22

traditional soap and water bed bath. This requires soap,

warm water, a washbowl (reusable or single use), washcloth,
towels, and possibly an emollient. Option two is the use of
pre-packaged specialist bed bath wipes that come already
impregnated with skin-friendly cleansers and moisturizers.
These wipes are designed for use straight from the packet,
and the cleansers and emollients delivered via the wipe are
formulated to nourish and hydrate the skin without the need
for rinsing and drying after use.
When performed correctly, either method will benefit
the patient; however, the more traditional soap and water
approach is typically more labour-intensive and has certain
well identified risks associated with it, which include
problems with skin hydration/dry skin (Dotz and Berman,
1983) and the risk of cross-infection (Greaves, 1985; Larson
et al, 2004; Johnson et al, 2009).
Peter Lamb/HFS Imaging

The impact of soap on skin integrity

Figure 1. The structure of the skin

Figure 2a. Equipment required for a soap and water bed bath

One of the greatest risks to dependent patients when

performing a traditional bed bath is the use of soap and its
impact on skin integrity. Both Bryant and Rolstad (2001)
and Skewes (1996) have reported that soaps can have a direct
impact on the epidermis and in addition to removing dirt
and debris from the skin surface, many soaps will also:
Remove the resident (beneficial) skin flora
Remove the natural lipid layer found on the skin
Increase skin pH as a result of their alkalinity
Interfere with the water-holding capacity of the skin
Thin the layers of the stratum corneum
Decrease natural skin lubricants.
These side-effects of soap will often result in dry, flaky
skin, which is more susceptible to cracking and tearing,
and this significantly impairs the important barrier function
performed by the epidermis, thereby reducing its ability to
protect the patient from transient and potentially pathogenic
bacteria, and leaving the skin (and therefore the patient)
more prone to infection.
Even when washing with a limited amount of soap, Bettley
(1960) reported that it can take a minimum of 45 minutes
for the skin pH to return to normal. Owing to the alkalinity
of soap, it generally has poor rinsing qualities and can leave
a residue or film on the epidermis, leading to skin sensitivity
and irritation. In addition, Kabarra and Brady (1984) have
reported that soap itself can harbour live pathogenic bacteria.

Limitations of the traditional bed bath method

Threats to skin integrity

Figure 2b. Equipment required for an Oasis bed bath

1410

Bryant and Rolstad (2001) highlighted that the soap and

water bed bath poses a number of threats to skin integrity
which can compromise the essential barrier function that
skin performs. Such threats include:
Water that is too hot has a drying effect on the skin
Some soaps dry the skin, remove resident skin flora and
increase skin pH, disrupting the acid mantle
The skin is subjected to both force and friction when
using normal wash cloths, which are lathered with soap
and rubbed on the skin in order to cleanse it
Washcloths may often be harsh or rough and can cause a
level of physical damage to the patients skin.

British Journal of Nursing, 2010, Vol 19, No 22

product focus
The risk of cross-infection
Reusable washbowls, washcloths and water can all pose a
serious risk of cross-infection to patients.
Washbowls
In 2009, Johnson et al reported the presence of both
meticillinresistant Staphylococcus aureus (MRSA) and
vancomycin-resistant enterococcus (VRE) in sampled
washbowls. This study supported earlier work by Joynson
(1978), which specifically identified wash bowls as the source
of an outbreak of Klebsiella.
Both Greaves (1985) and Johnson et al (2009) highlight
that inadequate cleaning, drying and incorrect storage
of reusable washbowls can contribute to the presence of
microbial biofilms and place patients at risk of crossinfection.
Washcloths
It is not unusual for the same wash cloth to be used
on a number of occasions to clean all areas of the body
(Greaves, 1985). This presents clear infection risks to the
patient by facilitating the movement of bacteria from
one area of the patients body to another. Ayliffe (1990)
recommends that bathing should be carried out with care
and that it is better to clean towards the naturally heavily
contaminated areas such as the rectum so that gram-negative
bacteria are not distributed over the rest of the body surface.
The work by Greaves (1985) identified that all washcloths
tested prior to patient bathing and irrespective of whether
they were tested wet or dry, all grew gramnegative bacilli.
Ayliffe (1990) states that it is always preferable to use
a fresh disposable wipe (washcloth) for each bath, and
that the same washcloth should never be used on more
than one patient without being properly washed and
dried. Ayliffe (1990) goes on to say that unless a fresh
disposable wash cloth is used each time, the patient may
be microbiologically dirtier at the end of the bath than at
the beginning.
Water
The water used during a bed bath becomes increasingly
contaminated with microorganisms. Greaves (1985) reported
that, by the end of the bed bath, the water is a soup of soap
and bacteria. The work by Greaves (1985) also reported
finding significant numbers of gram-negative bacilli and
S.aureus redistributed over the patients body as a result of a
soap and water bed bath.

The Oasis Bed Bath System

The Oasis bed bath system from Synergy Health is
available in packets of five or 10 single-use, disposable
wipes (Figures 3 and 4). The wipes are typically warmed
before use in order to enhance patient comfort. A
specially designed warming cabinet is available which stores
multiple packets at the correct temperature to ensure they
are ready for use straight from the warmer. Each wipe
comes ready for use with no need to add soap or water.
Each wipe should be used to clean an area of the body
(i.e. arm, leg, face, chest, genitalia). Once used, the wipe
should be discarded and a fresh wipe used for the next area

British Journal of Nursing, 2010, Vol 19, No 22

Recommended protocol when using the 5-wipe packet

Recommended protocol when using the 10-wipe packet

Figure 3. Recommended protocol when using the Oasis Bed Bath wipes

of the body to be cleaned (Figure 3). There is no specific

protocol to guide which Oasis Bed Bath product (five or
10 wipe packet) is the most appropriate for each patient or
for the healthcare provider. The decision of which product
to use typically comes down to one or more of the
following factors:
The personal preference of the nurse using the product
Policy of the healthcare provider
Patient needssome patients may only require a partial
bed bath
Cost.
The Oasis wipes are available in scented, unscented and
antibacterial product offerings. Shampoo caps are available
in scented and antibacterial. The single-use specialist bed
bath wipes provide patients and health professionals with a
number of important benefits over the traditional soap and
water method. These benefits are summarized below.

Skin hydration and protection

1411

wellbeing for the patients. When looking at the overall time

required for the bed bath procedure the efficiency savings
typically present in the following ways:
Reducing the time required to gather equipment (no need
for soap, water, washbowls, emollients, powder, towels)
No need to change the water during the bath (disposal of
used water and replacement with clean water)
No need for linen changes as a result of water spillages
No need to wash/disinfect, dry and store reusable
washbowls.
While there is scant information reporting direct views
from the patient, the work by Hocking (2009) reported
anecdotal comments from the nursing staff to the effect that
patients love the product and patients comment on how
refreshing they are.

Efficiency savings
Figure 4. The Oasis Bed Bath wipes and Shampoo cap

The combination of skin-friendly cleansers and emollients

within the bed bath wipes helps restore and maintain the
barrier function of the patients skin.

Reduced risk of cross-infection

Any risk of cross-infection associated with soap, water,
washbowls or washcloths is immediately eliminated and using
a fresh wipe for each area of the body reduces the risk of
spreading bacteria from one anatomical location to another.
McGuckin et al (2008) performed a 9-month study in an
intensive care unit (ITU) and reported a significant increase
in urinary tract infections (UTIs) after replacing singleuse
bed bath wipes with soap, water, washbowls and paper
towels. This rise in healthcare-associated infections (HCAI)
had significant cost implications for the ITU. Infections
are known to have a negative impact on patient wellbeing
(Madeo and Boyack, 2010); therefore, any increase in patient
infection rate will have a significant personal cost to the
individuals affected.
Recent work published by Madeo and Boyack (2010) on
the impact of Clostridium difficile infection has linked patient
infection to physical suffering, negative impact on activities of
daily living, and issues around privacy and dignity. Therefore,
avoiding an infection is likely to promote the health and
wellbeing of the patient, resulting in a more satisfactory
patient experience during their hospital stay.

Costs compared with the soap and water

bed bath
Comparing direct (material) costs for disposable bed bath
wipes versus soap and water shows that the costs can be
comparable with little difference between the two methods
(Larson et al, 2004; Hocking, 2009).
Indirect costs account for factors such as nursing
time (efficiency) and HCAI incidence. Therefore, any
improvements in efficiency or reductions in HCAI, as
reported by McGuckin et al (2008), will effectively result
in cost savings for the healthcare organization and improved

1412

Literature consistently reports improved efficiency when using the

disposable bed bath wipes. Hocking (2009) used Oasis Bed Bath
wipes on a 12-bedded ITU and saved an equivalent of 21 hours
in ITU nursing time per week (which correlates to approximately
15 minutes per patient bed bath). A study by Larson et al (2004)
reported that using a wipebased bed bath method eliminates
nursing time that would otherwise be spent gathering washbowls,
washcloths, soap, warm water (and changing the water mid-bath),
and emollients.

Improved patient experience

Since many patients may often experience pain or discomfort
as a result of manual repositioning and manipulation during
the bed bath, a more efficient process will improve the
patients bed bath experience

Ease of use/nurse satisfaction

Nurses consistently report positive responses when using
specialist bed bath wipes (Skewes, 1994; Hancock et al, 2000;
Sheppard and Brenner, 2000). Larson et al (2004) reported
that compared with the traditional bed bath, nurses expressed
a clear and significant preference for the disposable bath.
A product that evaluates well is more likely to be
successfully adopted into clinical practice.

The Productive Ward

The Productive Ward Initiative was launched in May 2008
by the NHS Institute for Innovation and Improvement
(NHS Evidence, 2010). It is designed to improve the ward
environment systems and processes. Any time released by
making processes more efficient can then be used for patient
care, leading to an improvement in the safety, quality and
reliability of both patient care and the patient experience.
The ProductiveWard is specifically focused on improvements
to processes, products or procedures that will result in (NHS
Evidence, 2010):
Releasing time to care for patients;
Improved quality of care
Improved patient safety
Improved staff morale
The potential to make financial savings by eliminating
waste and making processes more efficient

British Journal of Nursing, 2010, Vol 19, No 22

product focus

Table 2. Benefits offered by Oasis Bed Bath wipes over soap and water
Benefit

Patient benefit

Nurse benefit

Quicker, more efficient process

[less disruption]

More hygienic

Kinder to patient skin

Reduced risk of cross infection

Ease of use

Facility benefit

[time saving + less disruption

[time saving = efficiency savings]
to patient]

A previous evaluation of the Oasis Bed Bath wipes by

Hocking (2009) reported a weekly saving of 21 hours of
nursing time in a 12-bed ITU setting (thereby releasing
time to care for additional patient needs). Using the
Oasis wipes also improved quality of care (the wipes are
soapfree and skin-friendly) and patient safety (no risk of
crossinfection associated with washcloths, washbowls, soap
or water). The potential to make financial savings by using
the Oasis wipes to improve efficiency is further evidenced
in the following product evaluation undertaken across a
number of wards by the clinical procurement department at
Musgrove Park Hospital.
The role of clinical procurement within Musgrove
Park Hospital is to ensure that when new products or
concepts are being considered for adoption into the hospital
they not only offer the correct cost and/or efficiency
savings, but they manage to achieve this by simultaneously
offering equivalent or enhanced patient care and outcomes.
The ideal product is one which does both. Clinical

procurement ensure that products undergo a formal

evaluation with the correct patient group in the appropriate
clinical setting to ensure the products are fit-for-purpose
and offer a costeffective alternative to current products
and practices.
If a product evaluates well and achieves the appropriate
patient, cost and efficiency benefits, then it is recommended
to the Product Evaluation Selection Standardization Team
(PESST) for adoption into clinical practice.

Product evaluation
Clinical procurement wanted to streamline the bed bath
process for dependent patients. The intention was to improve
efficiency and provide a greater number of patients with their
bed bath at the appropriate time of day. The Oasis Bed Bath
wipes and shampoo caps offered the clinical procurement
directive a number of benefits over soap and water (Table 2).
It was paramount to ensure that any new products adopted
by the hospital:

Table 3. Potential return on Investment when adopting Oasis Bed Bath wipes
COSTS

Traditional bed bath

(towels, soap, water,
& pulp washbowls)

Oasis 5 wipe packet

Oasis 10 wipe packet

Per bath

Weekly cost*

Per bath

Weekly cost

Per bath

Weekly cost

DIRECT COST
0.84
(equipment only) cost
of bed bath

70.56
(89.16)**

0.86

72.24

1.17

98.28

25mins

35 hours

12 mins

17.5 hours

12 mins

17.5 hours

249.20

124.6

124.6

TOTAL WEEKLY COST

(DIRECT + INDIRECT)

338.36

196.84

222.88

TOTAL YEARLY COST

17594.72

10235.68

11589.76

EFFICIENCY SAVINGS /
YEAR COMPARED TO
SOAP AND WATER

7359.04***

6004.96***

INDIRECT
COST

Nursing time
Cost based
on HCA
band 2 at
7.12 / hour

*Weekly costs are based on bathing 12 patients per day for 7 days
**A soap and water bed bath using disposable (pulp) wash bowls incurs two additional costs
(1) Laundry costsdue to water spillages on bed linencosted by the site at 14.40/week
(2) Doubling up the pulp wash bowls in 50% of cases costs an additional 4.20/week
*** Efficiency savings will depend upon number of patients receiving a bath and the staff banding of the person performing the bath

British Journal of Nursing, 2010, Vol 19, No 22

1413

Key Points
n The

dependent patient relies on the bed bath in order to maintain a good

level of personal hygiene

n A

carefully undertaken bed bath can have a number of health, social and
physical benefits for the patient

n The

traditional soap and water bed bath is labour-intensive and can pose
some significant threats to the patient in terms of skin integrity and
crossinfection

n Alternative

bed bath methods are now available based on specialist wipes

that come ready to use and pre-impregnated with skin cleansers and
moisturizers
wipes such as the Oasis Bed Bath system are skin-friendly, reduce
the risk of cross-infection, and offer significant efficiency savings

Conclusions
Specialist bed bath wipes that overcome many of the
problems associated with the traditional soap and water bed
bath are now available. One such product, the Oasis Bed
Bath system from Synergy Health, is skin-friendly, eliminates
the crossinfection risk posed by soap, water, washbowls
and washcloths, and in product evaluations offers efficiency
savings of up to 50% per patient bed bath.
Improving efficiency, quality of care and patient safety
ensures that the Oasis wipes meet the needs of the Productive
Ward Initiative. Such products should be given careful
consideration by any facility that cares for the needs of the
dependent patient and wishes to improve the patient
experience while maximizing available nursing time to care
BJN
for patients.

n Specialist

n A

recent evaluation by the clinical procurement directive at Musgrove Park

Hospital reported a potential efficiency saving equivalent to 60007300
per annum when using the Oasis wipes in place of soap and water for 12
dependent patients
Were

fit for purpose and would confer a true benefit to

patients and/or clinical staff
Would be a cost-effective alternative.

Are Oasis Bed Bath wipes fit for purpose?

The wipes were trialled on dependent patients for 2weeks
across the following wards: orthopaedic, medical, respiratory,
endocrinology, rheumatology, and care of the elderly. Feedback
was overwhelmingly positive from both patients and staff, and
the wipes reduced nursing time from approximately 25 to
12minutes per bath.

Are Oasis Bed Bath wipes a cost-effective

alternative to soap and water?
To determine the impact that changing practice may have on
the hospital, clinical procurement undertook a comparison
in order to quantify the potential return on investment that
would be associated with the efficiency savings noted when
using the wipes on the appropriate (dependent) patients
(Table 3).

Summary
Not only were the Oasis wipes well liked by both patients and
nursing staff, they also significantly improved the efficiency of
the bed bath process. Based on bathing 12 dependent patients
per day, a yearly efficiency saving of between 6000 and
7300 can be made by adopting the Oasis wipes (Table 3).
The time saved when using the wipes can be used to provide
additional patient care, or for other clinical tasks.

1414

Conflict of interest: The author received support from Richard Forder

(Head of Clinical Affairs, Synergy Health) to write this article.
However, beyond this she received no funding, assistance or benefit of
any kind for this work.
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