Nurses’ compliance with central line associated blood stream infection prevention guidelines

Study design and setting

This study used a descriptive cross-sectional design with an observational non-active approach. The data collectors observed the guidelines under examination using a pre-structured observational sheet. The study was conducted in the ICUs of 15 hospitals located in 5 cities in Jordan: Amman, Irbid, Zarqa, Mafraq and Karak. The participating hospitals were 10 government, 4 private and one educational. All the ICUs were specialized adult medical-surgical units. Common indications for admission were neurological diseases, road traffic accidents and gastrointestinal emergencies. Seven ICUs had fewer than 7 beds, while 8 had 7 beds or more. These hospitals receive an average of 16,000 admissions and perform 5,000 central venous catheter insertion procedures annually. Data were collected over a 5-month period from March to July 2017.

The search for literature relevant to CLABSI prevention guidelines consulted the database of CINAHL, EBSCO, Medline and Cochrane Library using the key terms CLABSI, evidence-based practice, and nurses’ compliance, in medical and nursing journals from 2013 to the present.

Inclusion and exclusion criteria

Inclusion criteria in this study were: 1) registered nurse; 2) working as a full-time nurse in the ICU; 3) at least one year of experience. Nurses with less than one year of experience were excluded.

Sample size determination

G*Power software was used to calculate the sample size.18 Based on an estimated medium effect size (f²)=0.15, α=0.05, power=0.95, to run logistic regression with 4 independent variables, the required sample size was estimated to be 129. Two hundred nurses were approached, of whom only 171 agreed to participate, giving a response rate of 88%. The nurses who refused to participate were of different genders, ages and academic qualifications.

An observational sheet was developed based on existing CLABSI prevention guidelines from the Center for Disease Control and Prevention. The focus of the selected guidelines was the maintenance of the central line. The observational sheet consisted of 2 parts: general items (nurse-patient ratio, age, gender, academic qualification, position in department, years of experience, previous education on central venous catheter care, and availability of supplies, for instance, antibiotic impregnated central venous catheter); and 10 CLABSI prevention guidelines with 3 choices per item: “done completely and accurately” was given 2 marks, “done but not completely or accurately” was given one mark, and “not done” was given no marks. Nurses’ compliance scores lower than 10 were considered as “insufficient compliance”; while scores equal to or higher than 10 were classified as “sufficient compliance.” This scoring was based on a previous study conducted on a similar population of ICU nurses.19

During the observation, for each item if the nurse applied an action consistent with a CLABSI updated prevention guidelines at every opportunity the data collector documented “done completely and accurately”; if the nurse demonstrated an action inconsistent with CLABSI prevention guidelines or missed it on any opportunity it was “done but not accurately or completely”; and if the nurse failed to apply a guideline at every opportunity it was “not done”. One observational sheet was completed for each nurse even if the nurse took care of more than one patient. The observer changed the documentation in the checklist throughout the shift according to observed nursing activities. For example, if a nurse failed to apply a guideline once, the observer would change the item that was previously documented as “done completely and accurately” to “done but not completely or accurately.” The observers received an educational session on how to complete the observational sheet. No translation into Arabic was made as all observers demonstrated English language fluency.

A panel of experts comprising members of 3 nursing faculties, 2 infection control specialists and 5 ICU nurses participated in the validation of the initial draft of the instrument, which contained 13 items. The panel recommended rewording of some items to improve readability and understandability, and removal of 2 other items that were considered not nursing interventions: “using ultrasound guidance during insertion of the central venous catheter” and “removing the central venous catheter if the patient showed signs and symptoms of CLABSI”.

A pilot study was conducted to identify any difficulties. One more item was removed as it was difficult to observe “the use of a dedicated port for administration of total parenteral nutrition or blood”. The results showed that the observational checklist had very good internal consistency and reliability with Cronbach’s alpha of 0.82. Medical records in the participating hospitals were obtained and reviewed during the 5-month period of the study and were used to calculate the rate of CLABSI, length of hospitalization, duration of catheter and the rate of CLABSI-related mortality. The panel of experts approved the content validity of the final draft of the observational sheet.

The study was approved by the institutional review boards of the participating hospitals and the researcher’s university. Direct observations of nurses at the bedside were used to measure compliance. The observers were ICU nurses with infection control expertise who were not staff of the participating hospitals. They observed and documented use of the guidelines under investigation without participating in their implementation. They used a structured observational sheet as reference for the phenomena to be observed. An advertisement and short presentation about the study was made in each of the participating hospitals. The nurses were informed that observation would be made but the purposes of the study and the phenomena to be observed were not disclosed. The observers attended the ICUs of the participating hospitals, selecting available nurses who were assigned to care for patients with central venous catheter, and observing them for a whole shift. Once the observation was completed, the nurses were informed of the fact. If a nurse agreed to participate, the informed consent was obtained and the general items were completed from the participant and the response was documented on the sheet by the observer. If the nurse preferred not to participate, the observation was disregarded. All observations were conducted during day shifts. The observers were rotated between hospitals each month to prevent confirmation bias (Appendix 1).

Statistical analysis

The Statistical Package for the Social Science version 21 (IBM Corp., Armonk, NY, USA) was used to analyze the data.20 The means and frequencies for compliance scores were calculated. Nurses’ compliance scores were first calculated as a continuous variable then converted into a dichotomous variable; a score below 10 was considered as “insufficient compliance” and scores of 10 or above classified as “sufficient compliance.” This newly dichotomous nurses’ scores variable was the dependent variable in the logistic regression model.

Logistic regression with 4 independent variables was conducted to find out predictors of nurses’ compliance. The independent variables in the model were years of experience, previous education with CLABSI, nurse-patient ratio, and the ICU’s beds capacity. Adjusted odd ratios and 95% confidence intervals were calculated. Nagelkerke’s R² value was used to explain the variation in the dependent variable based on the model. Assumptions of regression were tested and none were violated. A collinearity diagnostic test was conducted to test if there was multicollinearity between the independent variables. No variance inflation factor (VIF) >5 was noted. The Hosmer-Lameshow Test was used to test if the data fit the model.

The Chi-Square test of association was used to discover if there was a relationship between the participants’ characteristics and the results of the observations for the items in the observational sheet. It was also used to compare the participants with sufficient compliance against their counterparts with insufficient compliance.