Assessment knowledge and practices of central line insertion and maintenance in adult intensive care units at a tertiary care hospital in Saudi Arabia.

BACKGROUND: Awareness of central line bundle by healthcare workers (HCWs) is essential for preventing catheter-associated bloodstream infections (CLABSI). The objective was to assess the knowledge and practice of insertion and maintenance central line bundles among HCWs in intensive care units (ICUs).
METHODS: A cross-sectional study was conducted at King Abdul-Aziz medical city in Riyadh between November 2017 and April 2018. The target was nurses and physicians working in three ICUs. The knowledge and practice were assessed using a structured study questionnaire that included also demographic characteristics.
RESULTS: A total 171 nurses and 41 physicians were included in the current analysis. More than 90% of HCWs correctly answered 9 out of 12 knowledge questions, specially questions related hand hygiene, maximal barrier, daily assessment, and dressing change. The overall knowledge score was 82% and was significantly higher among those who received central line bundle training. Self-reported compliance (all or most of the time) with 10 different bundle recommendations ranged between 50% and 97%, being highest with hand hygiene, maximal barrier, and using chlorhexidine (97% each) and lowest with using the subclavian site (50%). The overall self-reported compliance score was 87% and was significantly higher among nurses. There was weak positive correlation between knowledge and practice (correlation coefficient 0.266, p=0.001).
CONCLUSION: Knowledge and compliance of central line bundle were generally high in our HCWs. Training is important in improving knowledge of central line bundle. Future educational activities should focus on specific compliance deficiencies such as using the subclavian site and dressing change.

Background

Health care associated infections (HAIs) are infections that patients develop in healthcare setting while receiving care for another condition [1]. HAIs are one of the most common conditions that affect patients in the healthcare setting worldwide. Central line associated bloodstream infections (CLABSI) is one of the common and severe HAIs [2], [3]. Despite the fact that CLABSIs are largely preventable, CLABSIs are still frequently seen due to breaches in sterile technique while insertion of the catheter or administration of fluids, or during maintenance the catheter [2], [3], [4]. Physicians and nurses are frontline workers responsible for the insertion and care of central line. Additionally, nurses usually spend more time with patients compared with physicians [5]. CLABSIs increase cost through longer hospitals stay, excessive use of antibiotics and the potential of sepsis and ICU admission [6]. Reducing CLABSI incidence will provide better health care, safety and reduce cost [6]. Efforts to reduce and even eliminate such infections over the past years have been successful by applying evidence-based guidelines, CL bundles and removal of unnecessary lines [7].

Internationally, several studies showed the reduction of CLABSI rates after the utilization of central line bundles in their practice [8], [9], [10]. For example, a recent multicenter study published in 2017 reported 12.2% decrease in CLABSI rate after implementation of insertion and maintenance bundles in ICU setting [8]. Additionally, a study published in 2016 reported a 43% decrease in CLABSI and improvement in catheter care practices after the introduction of the central line care maintenance bundle in non-ICU setting [9]. Another study published in 2016 assessed the compliance with CLABSI prevention guidelines in countries with different economic statues [10]. The study showed that the staff was aware of the guidelines bundles, but they lacked adherence and application to these guidelines [10].

Locally, the rate of CLABSI is probably decreasing after implementation of central line bundle and other preventive measures. A surveillance study was conducted in six hospitals in three Gulf Cooperation Council (GCC) countries to compare their CLABSI rates with United States National Healthcare Safety Network (NHSN) and International Nosocomial Infection Control Consortium (INICC) [11]. The results showed that CLABSI risk was 33% lower than INICC but 146% higher than NHSN [11]. A number of local studies found that central line bundle implementation was associated with reduction of CLABSI rates in ICU setting [3], [12], [13]. However, successful implementation of central line bundles is dependent on several factors including knowledge and engagement of healthcare workers, specially nurses [14], [15]. The Aim of the current study was to evaluate the knowledge and practices of physicians and nurses working in different ICUs regarding the components of insertion and maintenance central line bundles such as hand hygiene, chlorhexidine skin antisepsis, dressing, and site of catheter insertion.

Methods

Setting and population: The study used a cross-sectional design and the population was physicians and nurses working in three adult ICUs; medical-surgical ICU, adult cardiac ICU and surgical ICU at King Abdul-Aziz Medical city (KAMC-R) in Riyadh in 2017. KAMC-R is 1000 bed tertiary care hospital served by approximately 2145 physicians and 5274 nurses. The three ICUs are 40 bed adult ICUs and served by 272 heath care workers. The percentage of central line utilization was approximately 85% of patient-days. Since physicians and nurse can work in many ICU's, no duplicates HCW were allowed.

Sample size: Assuming a knowledge or compliance percentage of 50% (associated with highest sample size) and a population size of 272 heath care workers, a total of 212 heath care workers was collected to detect 50% frequency with 5% margin of error at 95% confidence level.

Recruitment: The participants were recruited from three ICUs (medical, surgical, and cardiac ICUs) using a convenient sampling technique. There were no exclusion based on position and level of experience.

Data collection tool: The data were collected using a paper questionnaire was that was distributed from 25 November 2017 to 1 April 2018. It was developed based on the Ministry of the National Guard Health Affairs (MNGHA) administrative policies and procedures for CLABSI prevention. It consisted of three parts; demographic, knowledge, and practice. The demographic section consisted of categorical variables as gender, nationality, profession, type of ICU, and highest degree achieved; numerical data such as age, and years of experience. The second part included questions to assess the knowledge about insertion and maintenance central line bundles, and the third part included questions about self-reported compliance. The later was assessed by asking physicians and nurses about their related performance during the last month. The questionnaire was validated (face and content) by infectious disease consultant and epidemiologist and was piloted on 10 physicians and nurses working at ICU setting. Their response demonstrated good understanding of the questionnaire content without need for further modifications. The questionnaire was developed and pretested in English.

Ethical consideration: The study was approved by the Institutional Review Board (IRB) of King Abdullah International Medical Research Center's (KAIMRC). Written informed consent was obtained before starting the questionnaire. The questionnaire was self-administered and did not have any identifying information. No incentives or financial payments have been provided for the participation in the study.

Data analysis: This data collection was entered into an excel file. SPSS Version 23 was used for all statistical analysis. p-value <0.05 was considered as significant. Data was presented as mean and standard deviation (SD) for continuous variables (such as age) and frequency and percentages for categorical variables (such as gender and nationality). Knowledge score was created by summing up the responses to 12 questions; 2 for “yes”, 1 for “no”, and zero for “do not know”. Compliance score was created by summing up the responses to 10 Likert scale questions, ranging from “1: never” to “5: always”. Differences in knowledge by demographic characteristics were examined using chi-square for categorical data and t-test test for continuous data. The correlation between knowledge and compliance was assessed using Spearman's rank-order correlation.

Results

As shown in Table 1 the sample consisted of 212 individuals, of which 171 (81%) were nurses and 41 (19%) were physicians. The mean age of all participants was 35 ± 8 years, which was similar in nurses and physicians. Approximately 73.1% of all participants and 85.4% of nurses were females while 75.6% of physicians were males. Overall, 79% of all participants were non-Saudi. The majority (73%) were recruited from the medical ICU, 17.5% from the surgical ICU, and 6% from the cardiac ICU. Of all participants, 31% reported a specialization in ICU. More than half (61%) remembered receiving formal training on the central line bundle in the form of online course provided by the hospital or other accredited institutions. The mean duration of experience was 9.54 ± 7.55 years.

Table 1

Characteristics of healthcare workers recruited from intensive care unit (ICU) at KAMC Riyadh.

		Nurses(na = 171)		Physicians(na = 41)		Total(na = 212)
		na	%	na	%	na	%
Gender	Female	146	85.4	9	22	155	73.1
	Male	25	14.6	31	75.6	56	26.4
	Missing	–	–	1	2.4	1	0.5
Nationality	Non-Saudi	152	88.9	16	39	168	79.2
	Saudi	19	11.1	25	61	44	20.8
Ward	Medical ICUb	121	70.8	34	82.9	155	73.1
	Surgical ICUb	33	19.3	4	9.8	37	17.5
	Cardiac ICUb	10	5.8	3	7.3	13	6.1
	Missing	7	4.1	–	–	7	3.3
Specialized in ICUb		49	28.7	16	39	65	30.7
Received central line bundle training		111	64.9	18	43.9	129	60.8
Mean ± SDc
Age in Years (missing: 9)		35 ± 8		35 ± 9		35 ± 8
Years of Experience (missing: 9)		10 ± 7.6		7.31 ± 7.1		9.5 ± 7.6

Number.

Intensive care unit.

Standard deviation.

Table 2 demonstrates the knowledge section of the questionnaire which consisted of 12 questions. More than 90% of healthcare workers correctly answered 9 out of 12 knowledge questions. For example, 98%, 97%, 98%, and 91% correctly answered questions related hand hygiene, maximal barrier, daily assessment, and dressing change, respectively. Whereas 58% of healthcare workers correctly answered a question about the frequency of changing the administrative set and 65% correctly answered a question about iodine being the preferred preparation agent.

Table 2

Results of CLABSI knowledge questionnaire.

	Question	Yes	No	Do not know
1	The central line bundle is a group of evidence-based interventions when implemented together, result in better outcomes than when implemented individually.	91%	1%	7%
2	Hand hygiene is a key component of the evidence based central line insertion bundle.	98%	1%	1%
3	Wearing maximal barrier precautions (includes: Cape, Mask, and sterile gloves) is essential when insertion a central line.	97%	1%	2%
4	The patient should be draped with a full body drape (head to toe) prior to the insertion of the central line.	96%	2%	2%
5a	Iodine is not the preferred prep agent, as recommended by the Institute for Healthcare Improvement “Central Line Bundle” for adult patients.	65%	24%	8%
6	Choice of optimal selection catheter site is essential to prevent infection.	93%	3%	2%
7	Not documenting the details of the procedures in patient record is considered as noncompliance.	90%	5%	4%
8	Daily assessment of the central line is essential component to prevent infection.	98%	0%	1%
9	Unnecessary central lines should be removed immediately to prevention of infection.	98%	1%	1%
10a	Dressing change under aseptic technique is important for central line maintenance bundle.	91%	8%	1%
11	The administration set should be changed frequently.	58%	32%	7%
12a	After placement of central line has been verified, connecting previously used IV tubing to the new central venous access line is considered not ok.	89%	8%	3%

Questions 5, 10, and 12 were originally formulated as negative statements. The direction was changed to match the direction of the responses of other questions.

Table 3 demonstrates the self-reported compliance section of the questionnaire which consisted of 10 questions. Self-reported compliance (all or most of the time) with 10 different bundle recommendations ranged between 50% and 97%, being highest with hand hygiene, maximal barrier, and using chlorhexidine (97% each) and lowest with using the subclavian site (50%) and documenting dressing change (87%). The overall self-reported compliance score was 87%.

Table 3

Self-reported compliance with CLABSI procedure.

	Always	Usually	Sometimes	Rarely	Never
1	… performing hand hygiene before inserting a central line	94%	3%	0%	0%	2%
2	… wearing maximal sterile barrier precautions (mask, cape, gloves, gown) before inserting a central line.	94%	3%	0%	0%	1%
3	… using chlorhexidine to prepare the skin before inserting a central line.	95%	2%	1%	0%	1%
4	… waiting until the skin antiseptic is dry before puncturing the skin.	76%	16%	4%	1%	1%
5	… using the subclavian site for central line for adult patients.	23%	27%	37%	7%	3%
6	… documenting the procedure details (date, location, catheter lot number, name and signature of operator).	81%	13%	3%	0%	1%
7	… performing daily assessment of the central line necessity and document that in the patient record.	87%	6%	2%	1%	2%
8	… removing unnecessary central lines.	63%	30%	4%	0%	1%
9	… documenting the dressing changing details in the patient record.	77%	10%	4%	2%	7%
10	… following the recommended policy when changing the administration set.	83%	8%	3%	0%	4%

Assessment of knowledge and compliance and their relations to demographic characteristics are shown in Table 4. The overall average knowledge score was 82% and the overall self-reported compliance score was 87%. The knowledge score was significantly higher among those who received central line bundle training compared with those who did not (84% versus 78%, p = 0.014). The compliance score was significantly higher among nurses compared with physicians (89% versus 78%, p = 0.003). Additionally, non-Saudi had higher knowledge and compliance score compared with Saudi (83% versus 76%, p = 0.023 and 89% versus 79%, p = 0.005, respectively).

Table 4

Assessing the knowledge of and compliance with CLABSI procedure between healthcare workers by demographic.

		Knowledge (Mean ± SD)	p-value	Compliance (Mean ± SD)	p-value
Overall		82 ± 12		87 ± 21
Gender	Female	83 ± 09	0.092	88 ± 22	0.214
	Male	78 ± 18		84 ± 21
Nationality	Non-Saudi	83 ± 09	0.023a	89 ± 21	0.005a
	Saudi	76 ± 19		79 ± 23
Profession	Nurse	82 ± 13	0.374	89 ± 21	0.003a
	Physician	80 ± 11		78 ± 23
Ward	Medical ICU	81 ± 14	0.127	87 ± 22	0.860
	Surgical ICU	85 ± 05		89 ± 16
	Cardiac ICU	83 ± 07		89 ± 16
Specialized in Intensive Care	Yes	82 ± 13	0.167	88 ± 21	0.590
	No	79 ± 16		86 ± 18
Received central line bundle training	Yes	84 ± 08	0.014a	88 ± 22	0.389
	No	78 ± 18		85 ± 22

Significant using independent samples t-test.

A Spearman's rank-order correlation was run to assess the relationship between knowledge score and self-reported compliance as shown in Fig. 1. There was weak positive correlation between knowledge and practice (correlation coefficient 0.266, p = 0.001).

Fig. 1

Assessing the relationship between knowledge and self-reported compliance using spearman's correlation knowledge and compliance.

Discussion

Physicians and nurses who participated in the current study had high knowledge and compliance scores. The average knowledge score among participants is 82% and self-reported compliance is 87%. In comparison, a study was done in Peshawar, Pakistan, assessing the knowledge of central line bundles among ICU nurses using a similar questionnaire [16]. Their results showed a mean score of 74% [16]. Another cross-sectional study was conducted in Belo Horizonte, Brazil, estimated the knowledge central line bundles among healthcare workers at 42% and most individuals reported not receiving any training on central line bundles [17]. The high score in our study may be attributed to the training that healthcare professionals received. Additionally, there have been almost 10 years when the central line has been introduced in our hospital, making bundle as “practice norm”.

Training is a major factor when determining central line bundles knowledge and maintenance. Approximately 60% of the participants in the study have received central line training that either provided by the hospital or online course. The study revealed that health care workers who received training programs on CLABSI techniques had higher knowledge scores. This implicates the importance of receiving training. Although a week positive correlation between knowledge and practice was observed, significant association between education and practice could not be detected. Several studies support the implementation of an educational program to improve bundle knowledge and practice as well as to reduce CLABSI rate [18], [19], [20]. For example, a study was done in 2013 to compare the health care workers knowledge and compliance before and after the application of an educational program to reduce CLABSI rate showed that 99% of questions answered correctly by the staff after the training period compared to 60% answered accurately in the period before training [18]. Additionally, a study was done in 2015 to assess the effectiveness of educational programs on CLABSI rate in cardiac ICUs and the result showed that CLABSI rate reduced from 3.4 infections per 1000 central line days into 1.2 infections per 1000 central line after intervention [19]. All these results emphasize the importance of training new health workers on central bundles and guidelines.

Nurses in the current study had better compliance than physician. This has been observed in our institution specially with hand hygiene [21]. Nurse compliance is actually an integral part for the success of CLABSI prevention mainly through appropriate maintenance of central line [22]. The current finding may also explain the observed higher compliance among non-Saudi, as the majority of nurses in our study were nurses while the majority of physicians were Saudi.

Approximately 65% of the health care workers supported the use of chlorhexidine as a better antiseptic agent compared with Iodine. According to meta-analysis studies, chlorhexidine and povidone-iodine are equally appropriate to be used as an effective antiseptic [23]. However, compared with povidone-iodine, chlorhexidine has been linked to lower incidence of blood infections associated with the catheter and lower incidence infectious organisms within the catheter [18], [24].

Physicians in the current study showed lower compliance with the use of subclavian site for central line insertion for adult patients. This could be due to placement of subclavian catheter requires skills, training, and ultrasound guidance [25]. The internal jugular site was preferred since it is more accessible and associated with less complications compared with subclavian site according to literature [26]. Additionally, there was a concern about documenting dressing change. Future educational activities should focus on specific compliance deficiencies such as using the subclavian site and dressing change.

The current study had many strengths; the inclusion of both practice and knowledge in the questionnaire, the focus on both nurses and physicians, studying three different ICUs, and the use of a questionnaire based on the hospital polices. The presentation of data by type of healthcare workers enabled us to report nurses- and physicians-specific levels of knowledge and compliance. This may help hospital administrators to develop training programs for groups with lower rates of compliance to enhance the quality of care.

The current study had a number of limitations. First, our study used cross-sectional self-reported questionnaire. This design does not confirm causation. However, almost all studies examining knowledge and the compliance of central line bundles used a similar design. Second, our data was limited to adult ICUs in a single center, so the finding should be generalized only to tertiary hospitals with same ICU setting. Third, although the number of the physicians who participated in this study was less than the number of nurses, this reflected the nature of actual work space. Forth, since the sampling used in the current study was convenient sampling, probably health care workers who received central line bundle training were more motivated to participate in this survey, resulting in a higher compliance with recommended practices. However, our figures were similar to locally generated figures reported by infection control department.

Conclusions

Physicians and nurses who participated in the current study had generally high knowledge and compliance of central line bundles. Health care workers who received training programs on CLABSI techniques had higher knowledge scores. Nurses had better compliance than physicians. Future educational activities should focus on specific compliance deficiencies such as using the subclavian site and dressing change.

Funding

No funding sources.

Competing interests

None declared.

Ethical approval

Not required.