Our preceding qualitative investigation of bathing practices during weaning from PMV confirmed the importance of the bath as a fundamental nursing intervention that is highly valued by critical care nurses and family members [reference QUAL paper]1, 2
. The qualitative findings showed a general lack of consensus among ICU clinicians about the preferred timing or impact of baths during weaning trials. Observations of the weaning process did not show that bathing activity had an obvious positive or negative impact on the duration of PMV weaning trials; nor could we determine how prevalent the practice of bathing patients during PMV weaning trials actually was. Other qualitative reports show that nurse dependency, minimizing breathlessness, pacing or curtailing body care activities are critical strategies used by nurses and hospitalized patients with severe respiratory disease during bathing and personal body care3, 4
. Both patients and nurses endorse the importance of reducing or balancing energy demands during weaning from mechanical ventilation5–7
. Nurses interviewed in Jenny and Logan’s5
classic study reported using knowledge of the patient to tailor their interventions to manage each patient’s energy resources, including reducing energy demands during weaning and coordinating the patients’ activities. Although descriptive studies of mechanical ventilator weaning emphasize balancing work and rest, bathing during ventilator weaning trials or timing of bathing activities for patients who are weaning have not been specifically addressed.
Balancing work and rest may require nurses to control the timing of bathing activities in relation to the ventilator weaning trial. Tamburri and colleagues8
observed that a high proportion (62%) of routine daily baths were performed between 9:00 PM and 6:00 AM in intensive care units (ICUs). Their finding that more than one-third (56/147; 38%) of daily baths occurred between 2:00 AM and 5:00 AM suggests that patient sleep is frequently disrupted for the performance of hygiene care. There are no studies in the literature that specifically address the outcome of various bathing times (before ventilator weaning trial, during weaning trial, or nighttime bathing) or the impact of bathing on duration of mechanical ventilation (MV) weaning trials.
Past research suggests that most critically ill patients recover fairly quickly from the physiological effects of bathing and that the energy expenditure during bathing is not excessive. Bed baths and turning result in a transient decrease in mixed venous oxygen saturation (SvO2
) and variable effects on blood pressure in critically ill patients9–13
. Studies of activity in critically ill patients demonstrate relatively low levels of energy expenditure during a bed bath14, 15
. Decreases in SvO2
of 9 to 13% can be expected after bathing and/or turning with less of a decrease during the bathing phase9, 16
. The greatest decrease in SvO2
was associated with bed baths in mechanically ventilated patients on high inspired oxygen concentrations (FiO2
) and positive end-expiratory pressure (PEEP) settings10
. Physiological recovery from bathing and turning is usually relatively rapid, ranging from 3 to 16 minutes9–11, 13, 17
. No benefit was gained from the addition of a 10-minute rest period between bathing and turning phases of a bed bath in hemodynamically stable coronary artery bypass graft patients9
. Unfortunately, physiological studies of bathing have not been conducted during ventilator weaning trials or with patients who have experienced prolonged (> 4 days) critical illness and mechanical ventilation.
A previous literature review, suggested that age, severity of illness, and prolonged time on bed rest may be important factors influencing patient response to bathing and position changes during acute and critical illness18
. We were unable to identify any studies that attempted to determine the impact of the bath on duration of weaning trials in patients who required PMV.
There has been increasing attention to mobility interventions to improve outcomes in patients on PMV with evidence that activity and exercise can be feasible, safe, and effective in improving short term functional outcomes and in achieving earlier discharge for patients experiencing PMV 19–24
. Early activity studies and exercise protocols do include parameters regarding exercise during spontaneous breathing trials (e.g., not until patients have achieved 4 hours of spontaneous breathing) and/or guidelines to increase FiO2
concentrations during these activities21, 25
. Yet, the research literature provides no such guidance for “activities of daily living,” such as bathing.
In summary, qualitative studies identify significant concern about bathing and other energy expending activities in relation to balancing work and rest during weaning from mechanical ventilation. However, prior physiological studies suggest that critically ill patients recover fairly quickly from the physiological effects of bathing and that energy expenditure during bathing is not excessive. Daily timing of baths during critical illness are variable with nighttime bathing a frequent practice pattern. Patient demographic and clinical characteristics (e.g., age, duration of critical illness, severity of illness) may influence whether nurses bathe patients during the weaning trial.
In follow-up to our qualitative study of bathing practices and beliefs during weaning from PMV, available clinical record data were quantitatively examined to determine how often nurses bathed patients during PMV weaning trials and whether bathing patients before, during the weaning trial, or at night influenced the duration of weaning trials.
The specific aims of this quantitative secondary analysis were to (1) examine the bathing care patterns in patients weaning from PMV; (2) determine whether the bathing practice [during a weaning trial; within one hour before the weaning trial; and nocturnal (2:00 AM–5:00 AM)] is associated with the duration of the weaning trial; and (3) investigate the association between patient demographic and clinical characteristics for the initiation of bathing patients during a weaning trial. With respect to the third aim, we hypothesized that older, more seriously ill, and/or patients with longer periods of bed rest before weaning trials commenced, would be less likely to receive a bath during weaning trials early in their ventilator weaning period.