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Contents lists available at ScienceDirect

Journal of Infection and Public Health

journal homepage: http://www.elsevier.com/locate/jiph

Assessment knowledge and practices of central line insertion and

maintenance in adult intensive care units at a tertiary care hospital in
Saudi Arabia
Rasha S. Almahmoud a , Maha A. Alfarhan a , Walaa M. Alanazi a , Farah K. Alhamidy a ,
Hanan H. Balkhy b,∗ , Majid Alshamrani a,c , Aiman El-Saed a,c , Betule A. Sairafi a ,
Salim A. Bahron d
a
King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
b
World Health Organization, Saudi Arabia
c
Infection Prevention and Control Department, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs (MNGHA), Riyadh, Saudi
Arabia
d
Intensive Care Department, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs (MNGHA), Riyadh, Saudi Arabia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Awareness of central line bundle by healthcare workers (HCWs) is essential for preventing
Received 10 October 2019 catheter-associated bloodstream infections (CLABSI). The objective was to assess the knowledge and
Received in revised form 9 June 2020 practice of insertion and maintenance central line bundles among HCWs in intensive care units (ICUs).
Accepted 15 July 2020
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 knowl-
edge 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.
© 2020 Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences.
This is an open access article under the CC BY-NC-ND IGO license (http://creativecommons.org/
licenses/by-nc-nd/3.0/igo/).

Background another condition [1]. HAIs are one of the most common conditions
that affect patients in the healthcare setting worldwide. Central
Health care associated infections (HAIs) are infections that line associated bloodstream infections (CLABSI) is one of the com-
patients develop in healthcare setting while receiving care for mon 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 administra-
tion of fluids, or during maintenance the catheter [2–4]. Physicians
∗ Corresponding author at: Infection Prevention and Control, King Abdualziz Med-
and nurses are frontline workers responsible for the insertion and
ical City, Riyadh P.O. Box 22490, Saudi Arabia.
care of central line. Additionally, nurses usually spend more time
E-mail addresses: [email protected] (R.S. Almahmoud),
[email protected] (M.A. Alfarhan), [email protected] (W.M. Alanazi), with patients compared with physicians [5]. CLABSIs increase cost
[email protected] (F.K. Alhamidy), [email protected] (H.H. Balkhy), through longer hospitals stay, excessive use of antibiotics and the
[email protected] (M. Alshamrani), [email protected] (A. El-Saed), potential of sepsis and ICU admission [6]. Reducing CLABSI inci-
sairafi[email protected] (B.A. Sairafi), [email protected] (S.A. Bahron)

https://doi.org/10.1016/j.jiph.2020.07.009
1876-0341/© 2020 Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the CC BY-NC-ND IGO
license (http://creativecommons.org/licenses/by-nc-nd/3.0/igo/).

Please cite this article in press as: Almahmoud RS, et al. Assessment knowledge and practices of central line insertion
and maintenance in adult intensive care units at a tertiary care hospital in Saudi Arabia. J Infect Public Health (2020),
https://doi.org/10.1016/j.jiph.2020.07.009
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dence will provide better health care, safety and reduce cost [6]. age, and years of experience. The second part included questions to
Efforts to reduce and even eliminate such infections over the past assess the knowledge about insertion and maintenance central line
years have been successful by applying evidence-based guidelines, bundles, and the third part included questions about self-reported
CL bundles and removal of unnecessary lines [7]. compliance. The later was assessed by asking physicians and nurses
Internationally, several studies showed the reduction of CLABSI about their related performance during the last month. The ques-
rates after the utilization of central line bundles in their practice tionnaire was validated (face and content) by infectious disease
[8–10]. For example, a recent multicenter study published in 2017 consultant and epidemiologist and was piloted on 10 physicians
reported 12.2% decrease in CLABSI rate after implementation of and nurses working at ICU setting. Their response demonstrated
insertion and maintenance bundles in ICU setting [8]. Additionally, good understanding of the questionnaire content without need
a study published in 2016 reported a 43% decrease in CLABSI and for further modifications. The questionnaire was developed and
improvement in catheter care practices after the introduction of pretested in English.
the central line care maintenance bundle in non-ICU setting [9]. Ethical consideration: The study was approved by the Institu-
Another study published in 2016 assessed the compliance with tional Review Board (IRB) of King Abdullah International Medical
CLABSI prevention guidelines in countries with different economic Research Center’s (KAIMRC). Written informed consent was
statues [10]. The study showed that the staff was aware of the obtained before starting the questionnaire. The questionnaire was
guidelines bundles, but they lacked adherence and application to self-administered and did not have any identifying information.
these guidelines [10]. No incentives or financial payments have been provided for the
Locally, the rate of CLABSI is probably decreasing after imple- participation in the study.
mentation of central line bundle and other preventive measures. Data analysis: This data collection was entered into an excel
A surveillance study was conducted in six hospitals in three Gulf file. SPSS Version 23 was used for all statistical analysis. p-value
Cooperation Council (GCC) countries to compare their CLABSI rates <0.05 was considered as significant. Data was presented as mean
with United States National Healthcare Safety Network (NHSN) and standard deviation (SD) for continuous variables (such as age)
and International Nosocomial Infection Control Consortium (INICC) and frequency and percentages for categorical variables (such as
[11]. The results showed that CLABSI risk was 33% lower than gender and nationality). Knowledge score was created by summing
INICC but 146% higher than NHSN [11]. A number of local stud- up the responses to 12 questions; 2 for “yes”, 1 for “no”, and zero for
ies found that central line bundle implementation was associated “do not know”. Compliance score was created by summing up the
with reduction of CLABSI rates in ICU setting [3,12,13]. However, responses to 10 Likert scale questions, ranging from “1: never” to
successful implementation of central line bundles is dependent on “5: always”. Differences in knowledge by demographic characteris-
several factors including knowledge and engagement of health- tics were examined using chi-square for categorical data and t-test
care workers, specially nurses [14,15]. The Aim of the current test for continuous data. The correlation between knowledge and
study was to evaluate the knowledge and practices of physicians compliance was assessed using Spearman’s rank-order correlation.
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 Results
insertion.
As shown in Table 1 the sample consisted of 212 individuals, of
which 171 (81%) were nurses and 41 (19%) were physicians. The
Methods mean age of all participants was 35 ± 8 years, which was similar
in nurses and physicians. Approximately 73.1% of all participants
Setting and population: The study used a cross-sectional and 85.4% of nurses were females while 75.6% of physicians were
design and the population was physicians and nurses working in males. Overall, 79% of all participants were non-Saudi. The majority
three adult ICUs; medical-surgical ICU, adult cardiac ICU and sur- (73%) were recruited from the medical ICU, 17.5% from the surgical
gical ICU at King Abdul-Aziz Medical city (KAMC-R) in Riyadh in ICU, and 6% from the cardiac ICU. Of all participants, 31% reported a
2017. KAMC-R is 1000 bed tertiary care hospital served by approx- specialization in ICU. More than half (61%) remembered receiving
imately 2145 physicians and 5274 nurses. The three ICUs are 40 bed formal training on the central line bundle in the form of online
adult ICUs and served by 272 heath care workers. The percentage course provided by the hospital or other accredited institutions.
of central line utilization was approximately 85% of patient-days. The mean duration of experience was 9.54 ± 7.55 years.
Since physicians and nurse can work in many ICU’s, no duplicates Table 2 demonstrates the knowledge section of the question-
HCW were allowed. naire which consisted of 12 questions. More than 90% of healthcare
Sample size: Assuming a knowledge or compliance percentage workers correctly answered 9 out of 12 knowledge questions.
of 50% (associated with highest sample size) and a population size For example, 98%, 97%, 98%, and 91% correctly answered ques-
of 272 heath care workers, a total of 212 heath care workers was tions related hand hygiene, maximal barrier, daily assessment, and
collected to detect 50% frequency with 5% margin of error at 95% dressing change, respectively. Whereas 58% of healthcare workers
confidence level. correctly answered a question about the frequency of changing the
Recruitment: The participants were recruited from three ICUs administrative set and 65% correctly answered a question about
(medical, surgical, and cardiac ICUs) using a convenient sampling iodine being the preferred preparation agent.
technique. There were no exclusion based on position and level of Table 3 demonstrates the self-reported compliance section of
experience. the questionnaire which consisted of 10 questions. Self-reported
Data collection tool: The data were collected using a paper compliance (all or most of the time) with 10 different bundle rec-
questionnaire was that was distributed from 25 November 2017 ommendations ranged between 50% and 97%, being highest with
to 1 April 2018. It was developed based on the Ministry of the hand hygiene, maximal barrier, and using chlorhexidine (97% each)
National Guard Health Affairs (MNGHA) administrative policies and lowest with using the subclavian site (50%) and documenting
and procedures for CLABSI prevention. It consisted of three parts; dressing change (87%). The overall self-reported compliance score
demographic, knowledge, and practice. The demographic section was 87%.
consisted of categorical variables as gender, nationality, profession, Assessment of knowledge and compliance and their relations
type of ICU, and highest degree achieved; numerical data such as to demographic characteristics are shown in Table 4. The overall

Please cite this article in press as: Almahmoud RS, et al. Assessment knowledge and practices of central line insertion
and maintenance in adult intensive care units at a tertiary care hospital in Saudi Arabia. J Infect Public Health (2020),
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Table 1
Characteristics of healthcare workers recruited from intensive care unit (ICU) at KAMC Riyadh.

Nurses (na = 171) Physicians (na = 41) Total (na = 212)

a a
n % n % 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
a
Number.
b
Intensive care unit.
c
Standard deviation.

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 91% 1% 7%
when implemented individually.
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 65% 24% 8%
adult patients.
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 89% 8% 3%
considered not ok.
a
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
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%

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
a
Significant using independent samples t-test.

Please cite this article in press as: Almahmoud RS, et al. Assessment knowledge and practices of central line insertion
and maintenance in adult intensive care units at a tertiary care hospital in Saudi Arabia. J Infect Public Health (2020),
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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 guide-
lines.
Nurses in the current study had better compliance than physi-
cian. 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 mainte-
nance 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
Fig. 1. Assessing the relationship between knowledge and self-reported compliance of chlorhexidine as a better antiseptic agent compared with Iodine.
using spearman’s correlation knowledge and compliance. According to meta-analysis studies, chlorhexidine and povidone-
iodine are equally appropriate to be used as an effective antiseptic
average knowledge score was 82% and the overall self-reported [23]. However, compared with povidone-iodine, chlorhexidine has
compliance score was 87%. The knowledge score was significantly been linked to lower incidence of blood infections associated with
higher among those who received central line bundle training com- the catheter and lower incidence infectious organisms within the
pared with those who did not (84% versus 78%, p = 0.014). The catheter [18,24].
compliance score was significantly higher among nurses compared Physicians in the current study showed lower compliance with
with physicians (89% versus 78%, p = 0.003). Additionally, non-Saudi the use of subclavian site for central line insertion for adult patients.
had higher knowledge and compliance score compared with Saudi This could be due to placement of subclavian catheter requires
(83% versus 76%, p = 0.023 and 89% versus 79%, p = 0.005, respec- skills, training, and ultrasound guidance [25]. The internal jugular
tively). site was preferred since it is more accessible and associated with
A Spearman’s rank-order correlation was run to assess the rela- less complications compared with subclavian site according to lit-
tionship between knowledge score and self-reported compliance erature [26]. Additionally, there was a concern about documenting
as shown in Fig. 1. There was weak positive correlation between dressing change. Future educational activities should focus on spe-
knowledge and practice (correlation coefficient 0.266, p = 0.001). cific compliance deficiencies such as using the subclavian site and
dressing change.
Discussion The current study had many strengths; the inclusion of both
practice and knowledge in the questionnaire, the focus on both
Physicians and nurses who participated in the current study had nurses and physicians, studying three different ICUs, and the use
high knowledge and compliance scores. The average knowledge of a questionnaire based on the hospital polices. The presentation
score among participants is 82% and self-reported compliance is of data by type of healthcare workers enabled us to report nurses-
87%. In comparison, a study was done in Peshawar, Pakistan, assess- and physicians-specific levels of knowledge and compliance. This
ing the knowledge of central line bundles among ICU nurses using may help hospital administrators to develop training programs for
a similar questionnaire [16]. Their results showed a mean score groups with lower rates of compliance to enhance the quality of
of 74% [16]. Another cross-sectional study was conducted in Belo care.
Horizonte, Brazil, estimated the knowledge central line bundles The current study had a number of limitations. First, our study
among healthcare workers at 42% and most individuals reported used cross-sectional self-reported questionnaire. This design does
not receiving any training on central line bundles [17]. The high not confirm causation. However, almost all studies examining
score in our study may be attributed to the training that health- knowledge and the compliance of central line bundles used a sim-
care professionals received. Additionally, there have been almost ilar design. Second, our data was limited to adult ICUs in a single
10 years when the central line has been introduced in our hospital, center, so the finding should be generalized only to tertiary hos-
making bundle as “practice norm”. pitals with same ICU setting. Third, although the number of the
Training is a major factor when determining central line bundles physicians who participated in this study was less than the number
knowledge and maintenance. Approximately 60% of the partici- of nurses, this reflected the nature of actual work space. Forth, since
pants in the study have received central line training that either the sampling used in the current study was convenient sampling,
provided by the hospital or online course. The study revealed probably health care workers who received central line bundle
that health care workers who received training programs on training were more motivated to participate in this survey, result-
CLABSI techniques had higher knowledge scores. This implicates ing in a higher compliance with recommended practices. However,
the importance of receiving training. Although a week positive our figures were similar to locally generated figures reported by
correlation between knowledge and practice was observed, sig- infection control department.
nificant association between education and practice could not be
detected. Several studies support the implementation of an edu-
cational program to improve bundle knowledge and practice as
well as to reduce CLABSI rate [18–20]. For example, a study was Conclusions
done in 2013 to compare the health care workers knowledge
and compliance before and after the application of an educational Physicians and nurses who participated in the current study had
program to reduce CLABSI rate showed that 99% of questions generally high knowledge and compliance of central line bundles.
answered correctly by the staff after the training period com- Health care workers who received training programs on CLABSI
pared to 60% answered accurately in the period before training techniques had higher knowledge scores. Nurses had better com-
[18]. Additionally, a study was done in 2015 to assess the effec- pliance than physicians. Future educational activities should focus
tiveness of educational programs on CLABSI rate in cardiac ICUs on specific compliance deficiencies such as using the subclavian
and the result showed that CLABSI rate reduced from 3.4 infections site and dressing change.

Please cite this article in press as: Almahmoud RS, et al. Assessment knowledge and practices of central line insertion
and maintenance in adult intensive care units at a tertiary care hospital in Saudi Arabia. J Infect Public Health (2020),
https://doi.org/10.1016/j.jiph.2020.07.009
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Funding [11] Balkhy H, El-Saed A, Alansari H, Althaqafi A, Jameela J, AL Maskari Z, et al. Rates
of central line associated bloodstream infection in tertiary care hospitals in
three Arabian Gulf countries; six-year surveillance study. Antimicrob Resist
No funding sources. Infect Control 2015;4(S1) [Internet]. Available from: https://www.ajicjournal.
org/article/S0196-6553(17)30090-1/fulltext [cited 20 May 2020].
Competing interests [12] Ratna A, El-Saed A, Alsaif S, Tannous J, Dagunton N, Balkhy H. Effect of central
line bundle implementation on central line-associated bloodstream infection
rates in NICU in KSA. Int J Infect Control 2016;12(2) [Internet]. Available from:
None declared. https://www.ijic.info/article/view/15641 [cited 20 May 2020].
[13] Abdullah N. Epidemiology of Central Line-Associated Bloodstream Infection
(CLABSI) among patients in the intensive care units (ICUs) at a teaching
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[Internet]. Available from: https://criticalcare.imedpub.com/epidemiology-
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Please cite this article in press as: Almahmoud RS, et al. Assessment knowledge and practices of central line insertion
and maintenance in adult intensive care units at a tertiary care hospital in Saudi Arabia. J Infect Public Health (2020),
https://doi.org/10.1016/j.jiph.2020.07.009