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 Table of Contents  
INFECTION CONTROL PRACTICE
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 28-33

Step wise protocol for body wash in critically ill patients in intensive care units: An area/culture oriented approach


1 DepartmentofMedicalMicrobiology, PostGraduateInstituteofMedicalEducationandResearch,Chandigarh,, India
2 DepartmentofNursing, PostGraduateInstituteofMedicalEducationandResearch,Chandigarh,, India
3 DepartmentofAnaesthesiaandIntensiveCare,PostGraduateInstituteofMedicalEducationandResearch,Chandigarh,, India

Date of Submission19-Aug-2020
Date of Decision12-Oct-2020
Date of Acceptance20-Jul-2021
Date of Web Publication24-Sep-2021

Correspondence Address:
Dr. Kulbeer Kaur
DepartmentofMedicalMicrobiology,PostGraduateInstituteofMedicalEducationandResearch,Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpsic.jpsic_24_20

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  Abstract 


Background: During active surveillance done by Biswal et al. in 2017, to investigate fungal colonisation and infection in the trauma intensive care unit, several flaws were recorded in patient body wash protocol. Candida auris colonisation was rapidly increasing due to improper body washing. Several patients admitted eventually got colonised with C. auris at different body sites, predominantly in axilla and groin.
Aims: To devise a novel and simplified chlorhexidine-based body wash protocol to eradicate bacterial and fungal colonisers.
Materials and Methods: A detailed, systematic, standard and practical protocol for body wash depending on the specific work culture and resource availability is required to ensure standard nursing care. Therefore, a simplified chlorhexidine based, step wise body wash protocol to eradicate fungal colonisers which can be implemented and followed in every hospital setting was designed. This new protocol was implemented in the trauma intensive care unit (ICU) for 1 month. Successful implementation of the decolonisation procedure was assessed based on the feedback obtained from the nursing staff.
Results: The newly devised chlorhexidine based body wash protocol was successfully able to decolonise C. auris from the body sites such as axilla and groin of ICU patients. Easy and simplified protocol could be followed by nursing staff as well as patient attendants. Nursing staff provided positive feedback in implementing and following the new protocol.
Conclusion: The protocol can be easily implemented in any hospital settings with minimum resources. This new protocol can significantly reduce fungal and bacterial colonisation and hospital acquired infections.

Keywords: Clinical standards, infection control, intensive care, nurse's responsibilities, practice nursing


How to cite this article:
Kaur K, Kaur S, Shankarnarayan SA, Shylla N, Jain N, Biswal M, Jain K. Step wise protocol for body wash in critically ill patients in intensive care units: An area/culture oriented approach. J Patient Saf Infect Control 2021;9:28-33

How to cite this URL:
Kaur K, Kaur S, Shankarnarayan SA, Shylla N, Jain N, Biswal M, Jain K. Step wise protocol for body wash in critically ill patients in intensive care units: An area/culture oriented approach. J Patient Saf Infect Control [serial online] 2021 [cited 2021 Dec 5];9:28-33. Available from: https://www.jpsiconline.com/text.asp?2021/9/1/28/326621




  Introduction Top


Nursing care varies from country to country based on work culture, resources, knowledge, attitude, beliefs and individual differences. Ensuring uniform and standardised care to patients is one of the main challenges of any nursing manager. Personal hygiene of the patient such as toileting, bathing, grooming and general body hygiene are the highest priority in nursing practices.[1] Body washing of bed bound patients serves a few primary objectives such as assessing skin conditions, promoting skin circulation, comfort and relaxation along with reducing bacterial and fungal colonisation. It also removes perspiration, skin oils, dead cells and prevents body odour. Body washing also helps the nursing staff to assess the patient's physical status, such as skin integrity and ability to self-care.[2] A good hygiene increase the sense of wellbeing, helps in temperature regulation and affects sleep as well as hemodynamic status of patient.[3],[4] In intensive care units (ICUs), due to the limited mobility, comorbidities, antibiotics, immunodeficiency, use of multiple invasive devices, increased dependence and inadequate hygiene practices, patients are at higher risk of getting colonised and infected with hospital acquired multidrug-resistant organisms.[5] Therefore, effective personal hygiene procedures and thorough body washes are integral part of the personal hygiene program. However, according to a press release by the American Association of Critical Care Nurses (AACN), traditional method of bathing using basin soap and water can vary among caregivers. Furthermore, such procedures require longer duration and may lead to excessive skin drying, exposure to bacteria and increases the risk of healthcare-associated infection.[6] AACN also suggests prepackaged cleansers for body wash, but it is not feasible for low-to-middle economic class populated countries like India. Hence, in most of the hospitals traditional methods of body washing are being followed. Therefore, it is very important to make a detailed, systematic, standard and practical protocol for body washing using basin method in order to ensure uniform nursing care to the maximal level for all the patients.

Skin colonisation with the noncommensal and pathogenic microbes in prolonged hospitalised patients is a matter of concern. Biswal et al., tried to identify the route of Candida auris colonisation, degree of environmental contamination by infected or colonised patients as well as the effectiveness of control measures.[7] As part of the same effort, strategies were employed to eliminate C. auris from colonised sites using chlorhexidine body and mouth washes, environmental sites-using disinfectants and eradicating C. auris from contaminated hands of health care workers by training and improving hand hygiene compliance. During this study, an effective new body washing protocol using chlorhexidine gluconate 2% solution was designed to eradicate C. auris from the colonised sites of hospitalised patients.

In Indian government hospitals, most of the ICUs provide one to two body washes per day, depending on patient's status and availability of resources. First body wash is mostly done between 6 A. M to 8 A. M while second wash is given between 6 P. M to 8 P. M. The timings sometimes may fluctuate depending on patients' status, workload of nursing staff and availability of equipment. The standard duration of the cleaning procedure varies from15 to 20 min. The procedure may take less or more time depending on the patients' status and efficacy of nursing officer (NO) or assistant. Many a times, several reasons lead to non-compliance to standard protocol of body washing. Hence, the present study is an effort to present the simplified body wash protocol followed during the C. auris eradication program. We found that chlorhexidine gluconate solution (2%) was effective against C. auris by in vitro experiments, and hence employed in the body washing protocol for ICU patients.

Background

Several body wash protocols along with necessary rationale are depicted in many manuals, e-notes or books related to clinical nursing. Most of the protocols were designed for critically ill patients.[8],[9] Whereas some protocol are for relatively stable and oriented patients.[9],[10] These protocols do not inculcate infection control practices. According to Biswal et al. axilla and groin were the predominant sites colonised by yeast. Special attention to these areas of body during body washing is lacking in several standard procedures. Therefore, detailed body cleaning procedure exclusively for bed ridden, critically ill, ventilated patients with fractures where repeated movement of the patient is not possible is necessary to avoid hospital associated infection.


  Materials and Methods Top


The present protocol is designed according to challenges faced during body cleaning procedures in ICUs. The study has been approved by the institute ethics committee. Targeted patients are mostly sedated, ventilated and with multiple intervening devices. Tractions, plasters and/or dressings on the patients limit the patient movements. During the whole procedure the ABC i.e., Airway, Breathing and Circulation, of the patient status needs continuous monitoring by NO. The ventilator tubing needs to be monitored carefully. Therefore, it is important to carefully handle patient's movements during body wash procedure, and to complete the procedure within minimum duration, so that the patient monitoring can be started early. The procedure also does not include the face or ears, as they can be wiped while doing eye and oral care prior to body wash.

Procedure

Arrange the materials required for body wash as provided in [Figure 1] and [Figure 2].
Figure 2: Photograph of materials arranged on trolley before body wash in intensive care unit setting

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  • Sterile body wash set includes two basins, eight big gauze and two sponges
  • Trolley
  • At least five sterile gloves (four for assistant and one for NO)
  • Long mackintosh
  • Bathing top sheet
  • Luke warm water (30°C–45°C)
  • 2% chlorhexidine gluconate (2% CHG) solution or soap (as per unit policy) in a small bowl (In this study CHG 2% solution was used)
  • Loofah
  • Tray with two towels and extra cotton
  • Extra luke warm water bottle or jug
  • Dustbin
  • Clean bed sheet, melena sheet and diaper
  • Clean or sterile gown


Special emphasis must be given to following points:

  • Trolley will only be touched by the NO. She/he will provide materials to assistant in hand and pour CHG on the gauze from above
  • Never replace gauze in the basin, if needed additional cotton may be used for axilla and groin
  • Make sure that the contact time of 2% CHG solution should be at least 2 min if possible.


To successfully carry out the procedure one NO and one assistant are required (In Indian hospitals most of the assistance work is done by patient's relatives only)

Newly devised protocol consists of the following steps:

  1. Assess patient for need of body wash and feasibility for it


  2. Note: Always check with the doctor if the patient is stable

  3. Check basal vital signs of patient and ensure the optimum room temperature
  4. Bring the articles to bed side using a procedure trolley [Figure 2]
  5. Maintain privacy
  6. emove diaper, clean the stool of patient if required using hand hygiene. Discard the diaper
  7. Remove gown, ECG leads, BP cuff and Foley's catheter fixation dressing of the patient under doctor's and technician's supervision. Place the leads at the head side trolley of patient. Put the top sheet and gown in hamper


  8. Note: Removal of ECG leads and BP cuff depends on patient status.

  9. ECG leads, and BP cuff surface can be disinfected with any appropriate disinfectant available simultaneously and place them at clean and dry place for reuse after procedure (an inside portion of gloves pack cover may be used for this purpose) Remove the bed sheet and put in hamper. Use long mackintosh under the patient and cover the patient with top sheet
  10. NO will stand with trolley at his/her dominant hand side and assistant will be on the other side of bed
  11. Follow hand hygiene and put on gloves
  12. NO: Adjust top sheet. Take wet gauze 1 from luke water filled in basin 1 and pour few drops on one axilla without touching the skin. Apply CHG solution on the same gauze and give to the assistant
  13. Assistant: Take CHG gauze1 from the NO and apply CHG solution to the axilla using 10-15 gentle strokes depending on patient's skin status. Discard the gauze


  14. Repeat the step 10 and 11 for other axilla followed by groin.

  15. Assistant: Remove gloves, do hand washing and put on new gloves


  16. Note: Starting with axilla and groin will give it more contact time with CHG solution.

  17. NO: Adjust top sheet. Wet the areas with sponge1 from basin 1 in area I [Table 1] and place the sponge 1 back in basin 1
  18. NO: Apply CHG solution with loofah on area I. Keep the loofah back in CHG bowl. Loofah makes it easy to apply CHG solution on skin, but soft mitten can be used based on skin type of patient
  19. NO: Use wet sponge 2 from luke water filled in basin 2 to clean the CHG solution from area I. Keep the sponge back in the basin 2
  20. Use the steps 13, 14 and 15 for area II followed by area III
  21. Assistant: Ask NO to hand over the wet gauze 4, and clean one axilla. Use wet gauze 5 for other axilla, followed by wet gauze 6 for groins. Clean the areas gently. If required, more water and extra cotton may be taken from the NO. Discard the gauze. Never put the used gauze back in the basin
  22. Assistant: Remove gloves, perform hand washing and put on new gloves
  23. NO: Dry the area I to III, axilla and groin with towel 1 in sequence. Keep the towel 1 separately for washing and sun-dry
  24. Assess airway of the patient, and change the position of patient with the help of assistant
  25. heck the status of skin integrity at back and other pressure points, and manage accordingly if needed
  26. NO: Take wet gauze 7 and pour few drops on patient's buttocks without touching the skin. Apply CHG solution on the same gauze and give to the assistant
  27. Assistant: Apply CHG solution using 10-15 gentle strokes. Discard the gauze


  28. Note: CHG should be applied from outer buttocks to inner area near anus.

  29. Assistant: Remove gloves, do hand washing and put on new gloves
  30. NO: Use sponge 1 from basin 1 to wet the back. Put the sponge 1 back in basin 1. Apply CHG solution to back using loofah or soft mitten. Put loofah or soft mitten back in CHG bowl
  31. Let the CHG in contact with skin for 30 s to 2 min, depending on the patients' status, sedation and cooperation
  32. NO: Change water of basin 2 if soiled. Clean the back with sponge 2 from basin 2
  33. Assistant: Ask NO for gauze 8 from basin 2. Clean the buttock followed by area around anus gently. Ask for extra cotton and water if needed. Discard the gauze and cotton
  34. Assistant: Remove gloves and do hand washing. Use new gloves if needed
  35. NO: Dry the back followed by buttocks with towel 2. Keep the towel at side for washing and sun-dry
  36. NO: Check for skin dryness and manage accordingly after taking recommendations by the doctor in charge
  37. Remove mackintosh, put fresh bed sheet and melena sheet. Place the patient in comfortable position
  38. Remove bathing top sheet. Put fresh gown and diaper to the patient
  39. Reattach ECG leads, BP cuff and other fixations to the patient
  40. Check vitals of patient
  41. Terminate the procedure
  42. Do hand hygiene
  43. Do the recording and reporting (if any)
Table 1: Body areas (sequence of washings given to different body parts)

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Post procedure measures:

  1. Send the sponges to the laundry, and wash the basins with detergent and warm water
  2. Make fresh body wash pack and send for sterilisation if possible
  3. Ask assistant to wash the towels in hot water (80°C) and sundry the towel at clean place and store in clean and dry place for next use, or use fresh from the laundry (if hospital supply)
  4. Wash the loofah in hot water, sundry and store in clean and dry covered kit or area for reuse.


Evaluation phase

Above protocol was practiced by the NO working at Advanced Trauma ICU at PGIMER, Chandigarh, India, for 1 month. Feedback was collected from 22 NO using feedback form [Table 2].
Table 2: Feedback form for body wash procedure using Chlorhexidine gluconate solution (please tick the appropriate response and answer questions)

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  Results Top


The newly devised protocol was followed by the NO of the Trauma ICU for 30 days. This protocol was followed twice a day for all the patients admitted. At the end of the month, the feedback was collected from 22 NO who carried out the protocol in the Trauma ICU. Seventeen out of total 22 participants were females and four were males, one participant did not disclose the gender. Twenty participants were <30 years of age. Seventeen of them were holding a bachelor's degree in nursing whereas three were diploma degree holders and one participant had masters' degree in nursing. Nursing experience ranged from 6 months to 7 years (mean = 2.3 years). Response of the NO on details of newly devised cleaning protocol is provided in [Figure 3], [Figure 4], [Figure 5]. Reason for hindrance during practice was also explored so that the newly devised protocol may be modified for the better care of patients and ease of following the procedure. Based on the responses from 22 participants, followings were common hindrances:
Figure 3: Response of the nurses after one month trial of the body wash procedure

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Figure 4: Feedback from nursing officers on practical feasibility of new protocol

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Figure 5: Nursing officers followed the procedure after training

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  1. Critical condition of patient including multiple fractures or not to remove traction or multiple in situ tubings
  2. Lack of time
  3. Uncooperative or low understanding level of assistant (due to shortage of staff, help of patient relatives were taken as assistants)
  4. Lack of interest, stat orders, lack of resources.



  Discussion Top


The most challenging part for enactment of any nursing procedure is to convince nursing personnels regarding the procedure as the nursing procedure makes complete sense only if it is being followed. As already mentioned, the formation of revised body wash protocol was needed because the ICU and microbiology personnel team was not able to remove the C. auris colonisation from axilla or groin in patients using the traditional body wash procedure. Therefore, it was necessary to incorporate complete, systematic and infection control related approach for the body wash procedure. The procedure was modified based on the area specific challenges and availabilities. The new procedure not only fulfil the above needed requirements, but as it was made taking the feedback of the ICU NOs, senior NOs, assistant nursing superintendent, OT technician, anaesthetist, microbiologist and infection control nurse, the procedure was also practically possible. The NO not only followed the procedure till the decolonisation of C. auris, they continued the same procedure even after that and incorporated in routine practice. Furthermore, it was easier for infection control nurse to pursue the NO of other ICUsto follow the same procedure.

Another perspective to look into with great sensitivity is that the patients in countries like India need more extensive bed bath in ICUs (at least for first few days). Most of the patients usually come to ICU after a short stay in emergency area for around 2–3 days and sometimes even more due to unavailability of beds in ICUs. The patient burden in emergency areas [Figure 6] is very high. Shortage of staff or infrastructure liabilities further leads to ignorance of personal hygiene like bed bath. In addition, in most of the Indian hospitals there is no job category as nursing aid or practical nurse as observed in other countries. In India, registered nurse i.e. NO takes care of patient hygiene, counselling and explaining the medical conditions, which further leads to increase workload on the NO especially in areas like emergency. Therefore, most of the patient in ICUs needs more CHG solution or soap gauze strokes during body wash than in less populated and developed nations where either patient load is less or ample NO are available.
Figure 6: Patient burden in the emergency of our institute

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Thus, step wise elaborated protocol using the input of local NO and available resources proves to be the only good solution to the patient body hygiene. There should essentially be the area or culture oriented approach to most of the nursing care procedures including body wash.


  Conclusion Top


The newly devised protocol was able to eradicate C. auris from the patient's axilla and groin. The procedure was found feasible by most of the NO. In some exceptional circumstances based on patient condition, procedure can be modified based on individualistic observations. However, for most of the situations in ICU or wards, this body wash procedure proved to be effective and feasible.

What does this paper contribute to the wider global community?”

  1. Body wash for critically sick patients is different from the ambulatory patients. The present protocol is made for the critically sick ICU patients, who are at the risk of increased bacterial and fungal colonisation especially at axilla, groins and other moist areas
  2. The step wise body wash protocol is meticulous, systematic and practical which ensures quality nursing care globally
  3. The protocol also elaborates on all the infection prevention perspectives which were lacking in other body wash procedure described earlier.


Acknowledgement

We would like to acknowledge all the NOs of Advanced Trauma Centre ICU, PGIMER, Chandigarh, India, for their participation and cooperation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Derde LP, Dautzenberg MJ, Bonten MJ. Chlorhexidine body washing to control antimicrobial-resistant bacteria in intensive care units: A systematic review. Intensive Care Med 2012;38:931-9.  Back to cited text no. 1
    
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Tollefson J, Toni B, Jelly E, Watson G, Tambree K. Clinical Skills for Enrolled/Division 2 Nurses. In: Smith G, editor. Business. 1st ed. New Zealand: Cengage Learning; 2010.  Back to cited text no. 2
    
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Coyer FM, O'Sullivan J, Cadman N. The provision of patient personal hygiene in the intensive care unit: A descriptive exploratory study of bed-bathing practice. Aust Crit Care 2011;24:198-209.  Back to cited text no. 3
    
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Grealy B, Chaboyer W. Essential nursing care of the critically ill patient. In: Elliott D, Aitken L, Chaboyer W, eds. ACCCN's Critical Care Nursing. 2nd ed. Sydney, Australia: Elsevier–Mosby Australia; 2012: 105-32.  Back to cited text no. 4
    
5.
Bonten MJ. Ventilator-associated pneumonia: Preventing the inevitable. Clin Infect Dis 2011;52:115-21.  Back to cited text no. 5
    
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AACN Issues New Protocols for Bathing Patients | Nursing News, Stores and Articles | Nurse.com Blog. (n.d.). Available from: https://www.nurse.com/blog/2013/04/21/aacn-issues-new-protocols-for-bathing-patients-2/. [Last accessed on2017 Dec 21].  Back to cited text no. 6
    
7.
Biswal M, Rudramurthy SM, Jain N, Shamanth AS, Sharma D, Jain K, et al. Controlling a possible outbreak of Candida auris infection: Lessons learnt from multiple interventions. J Hosp Infect 2017;97:363-70.  Back to cited text no. 7
    
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Singh H, Vishwanathan RP, Noornisha, Ramachandiran V, Kumari V, Menaka, et al. Nursing. Higher secondary book-1st year. Tamilnadu textbook cooperation. Govt. of Tamilnadu. First ed. 2004. Pp 258-61.  Back to cited text no. 8
    
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Patidar J. (n.d.). Fundamental of Nursing Procedure Mannual. Available from: https://www.slideshare.net/drjayeshpatidar/fundamental-of-nursing-procedure-mannual. [Last accessed on 2018 Feb 08].  Back to cited text no. 9
    
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Khadka S, Kisi D, Raya P, Shreestha S. Fundamental of nursing procedure manual for PCL course. Japan international cooperation agency (JICA), Nepal office. 2008:26-29. https://www.jica.go.jp/nepal/english/office/topics/pdf/topics02_01.pdf.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2]



 

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