Central-line-associated bloodstream infection (CLABSI) can result as a complication of total parental nutrition (TPN). Nurses working in critical care settings need appropriate knowledge and skills relating to prevention of CLABSI in the context of administering TPN. However, in critical care settings in India this knowledge may be lacking.
Fonseca et al (2016) conducted a retrospective study on the relationship between TPN and CLABSI and found that in patients who had central venous catheters (CVCs) inserted (n=12 868), 1253 patients received TPN, with 1106 developing CLABSI. Results from multivariate regression analysis showed that TPN (OR, 2.20; 95% CI, 1.59–3.04) was a significant risk factor for CLABSI. Another retrospective study by Reitzel et al (2019) identified CLABSI cases in 38 of the 1762 patients receiving parenteral nutrition (PN) (1.73 episodes of CLABSI per 1000 PN days). The study concluded that patients receiving PN are at higher risk for both infectious and non-infectious catheter complications. Compared with national averages of CLABSI, the prevalence of catheter-related Candida bloodstream infection (candidaemia) in the population of cancer patients receiving PN was higher. This study highlighted the need for development of more effective, targeted preventive interventions.
Bord et al (2020) evaluated nursing knowledge and practice regarding TPN administration and concluded that periodic audits to assess TPN practice combined with knowledge assessments are needed to improve and sustain compliance with standards of care for TPN administration. Meanwhile, Mohapatra et al (2020) conducted a prospective study on the impact of continuous education and training to reduce CLABSI in an intensive care context and concluded that adherence to hand hygiene and catheter hub care with continuous teaching, training and supervision was highly effective in reducing the CLABSI rate. Therefore, there is a need to educate nurses working in critical care units regarding CLABSI and TPN-associated complications. There is also a need to develop protocols and checklists for practice and procedure for TPN administration, CVC insertion and care, to check that standard guidelines and practices are being followed.
This article discusses the evaluation of a skills competency programme aimed at improving prevention of CLABSI by nurses in critical care settings administering TPN.
Aim
Objectives
- Develop and validate a skills competency programme on the prevention of CLABSI due to TPN administration
- Assess the pre-test knowledge and practice on the prevention of CLABSI due to TPN administration, among staff nurses working in critical care units in both an experimental and control group
- Evaluate the effectiveness of the skills competency programme by comparing the pre-test and post-test knowledge and practice scores of the control and experimental groups
- Find the correlation between post-test knowledge and practice scores in the experimental group regarding the prevention of CLABSI due to TPN administration, to understand the effects of knowledge on practice
Methods
Design
The research design selected for the present study was quasi-experimental: non-equivalent group, pre-test post-test design.
Setting
The study was conducted at Chhatrapati Shivaji Subharti Hospital, Meerut, India, and Lala Lajpat Rai Memorial (LLRM) Medical College, Meerut, India. This study was conducted among staff nurses working in the medical intensive care unit (MICU), surgical intensive care unit (SICU), coronary care unit (CCU), respiratory intensive care unit (RICU) and neurological intensive care unit (neuro ICU).
Sample
The sample method was non-probability: a purposive sampling technique was used to select the participants. The total sample size was 80 nurses, 40 in the control group (critical care nurses at LLRM Medical College) and 40 in the experimental group (critical care nurses at Chhatrapati Shivaji Subharti Hospital).
Inclusion criteria were: staff nurses from critical care units (MICU, RICU, SICU, CCU and neuro ICU) only, who were available at the time of data collection and willing to participate in the study. Exclusion criteria were: staff nurses who were on relief duty in critical care units, and staff nurses with less than 6 months' experience working in critical care units.
Tools and scoring procedure
The first questionnaire collected information on seven demographic variables: age, gender, qualification, experience, area of work, previous administration of TPN (how often), and previous experience with treating patients with CLABSI.
The second tool was a structured knowledge questionnaire, developed by the first author, covering TPN in general, TPN preparation and administration, TPN monitoring and complications, CLABSI, and prevention of CLABSI due to TPN administration. Each of the 27 questions carried 1 mark.
The reliability coefficient of the structured knowledge questionnaire was calculated using Cronbach's alpha. The value for the reliability was r=0.8, therefore, the tool was found to be reliable.
Practical assessment
Practice was assessed through a series of OSCE (objective structured clinical examination) stations. At station 1, there were images of five items of equipment required for the TPN administration procedure, and participants were asked to identify the name of each item (1 mark each for a total score of 5). The equipment shown was: TPN (3-in-1) bag, infusion pump, infusion filter, central venous catheterisation kit, and central line port caps.
Station 2 covered the process of TPN administration with a checklist of 27 points, 10 of which were ‘red flags’ (Table 1). The checklist was developed by the first author, drawing on the American Society for Parenteral Nutrition (ASPEN) safety consensus guidelines (Ayers et al, 2014) and taking into account the ASPEN model for TPN competences (Guenter et al, 2018). Each item on the checklist scored 1 point if performed correctly, and for every red flag item that was missed 1 point was deducted. The scores and number of red flags were used to assess competence in administering TPN and level of risk for CLABSI and other complications (Table 2).
Table 1. OSCE station 2: TPN administration checklist (for superviser)
| No. | Step | Met | Unmet | Red flag* |
|---|---|---|---|---|
| Pre-procedure | ||||
| 1 | Rechecks patient's identity | |||
| 2 | Verifies central venous catheter is properly inserted with tip into the SCV and condition of site is healthy | |||
| 3 | Rechecks physician's order for TPN | |||
| 4 | Checks TPN bag for labels, contents and patient's name (when hospital made) | |||
| 5 | Inspects bag for leakage, tears, visible particles or precipitates, any other abnormalities | |||
| 6 | Confirms rate of infusion for TPN and D5 solution with the physician | |||
| 7 | Removes TPN from the refrigerator at least 1 hour before administration | |||
| 8 | Washes hands and wears gloves | |||
| 9 | Correctly adds medications (as prescribed) to the TPN bag using aseptic technique | |||
| 10 | Explains procedure to the patient | |||
| 11 | Assembles all the articles (tubing, infusion pumps etc) | |||
| During procedure | ||||
| 12 | Washes hands and wears gloves | |||
| 13 | Scrubs the port with alcohol swab | |||
| 14 | Aspirates using syringe and flushes the lumen to be used with saline | |||
| 15 | Attaches administration tubing to lumen of CVC correctly using aseptic technique | |||
| 16 | Clamps all unused lumens tightly | |||
| 17 | Begins infusion at a constant rate | |||
| After procedure | ||||
| 18 | Stops TPN and flushes the lumen with saline | |||
| 19 | Disconnects TPN and removes tubing. Clamps all unused lumens and covers with sterile gauze | |||
| 20 | Discards all articles as per hospital protocol | |||
| 21 | Documents procedure on patient's chart | |||
| Monitoring protocol | ||||
| 22 | Patient response and assessment for TPN complications | |||
| 23 | Blood glucose | |||
| 24 | Vital signs | |||
| 25 | Intake and output | |||
| 26 | Blood tests and lab reports | |||
| 27 | Daily body weight | |||
CVC=central venous catheter; SCV=subclavian vein; TPN=total parenteral nutrition
Source: adapted from Ayers et al, 2014; Guenter et al, 2018Table 2. OSCE station 2: scoring considerations for TPN administration
| A. Level of competence, based on steps of procedure performed as per checklist | ||
|---|---|---|
| % | Level of competence | Details |
| 90–100% (25–27 steps) | L4 | Can perform independently |
| 80–89% (22–24 steps) | L3 | Can perform independently with minimum supervision |
| 70–79% (19–21 steps) | L2 | Can perform with continuous supervision |
| ≤69% (≤18 steps) | L1 | Cannot perform without appropriate training and education |
Station 3 showed participants images of two cases of phlebitis and they were expected to identify the phlebitis score using the Visual Infusion Phlebitis scale (Jackson, 1998). Each case carried 1 mark, for a total of 2 marks.
Station 4 assessed participants against a checklist for CVC care and maintenance. This had 10 items, each worth 1 point (Joint Commission, 2013a; 2013b) (Table 3).
Table 3. OSCE station 4: central line care and maintenance checklist
| Critical steps | Yes | No | n/a | Notes/comments |
|---|---|---|---|---|
| Necessity assessed If no longer needed, remove, indicating details of removal in the records (including date, location and signature and name of operator undertaking removal) | ||||
| Injection sites are covered by caps or valved connectors | ||||
| Caps changed (as per hospital protocol) | ||||
| Hub scrubbed with alcohol-chlorhexidine swab | ||||
| Accessed with (indicate type and size of needle) | ||||
| Insertion site without evidence of infection | ||||
| Dressing intact and labelled properly | ||||
| Dressing changed today | ||||
| Catheter stabilised as traction on line | ||||
| Administration set replaced and labelled this size? |
Overall, the total possible knowledge score was 27, and the total possible practice score, including all 4 OSCE stations, was 44.
Skills competency programme
A skills competency programme, devised by the first author drawing on a range of educational materials, was administered to the experimental group (those at Chhatrapati Shivaji Subharti Hospital) to educate them about TPN, its administration, TPN monitoring and complications, CLABSI and prevention of this during TPN administration. The programme used a combination of OSCE stations to improve the skills of nurses and lectures assisted with PowerPoint presentations to improve their knowledge. The content covered was:
- Introduction to and definition of TPN
- Indications and contraindications for TPN administration
- Basic adult daily requirement for TPN
- Composition and types of TPN
- Procedure for TPN preparation
- Procedure for TPN administration
- Equipment required for the procedures related to TPN administration
- Components of assessment and monitoring of patients receiving TPN
- Complications of TPN administration
- CLABSI meaning and definition
- Causes of CLABSI
- Signs and symptoms of CLABSI
- Diagnostic tests and diagnostic criteria for CLABSI
- Strategies to prevent CLABSI (CLABSI bundles: central line insertion bundles and central line care and maintenance bundles in detail).
Data collection procedure
The data for the main study were collected for 4 weeks in January 2022. The main study was conducted at Chhatrapati Shivaji Subharti Hospital and LLRM Medical College only after obtaining permission from the authorities concerned.
The purpose of the study was explained to participants and written consent was taken from all.
On the first day, rapport was maintained with the nurses and the demographic data were collected. Following this, on the same day, the structured knowledge questions administered and the OSCE stations were used to conduct a pre-test to assess the nurses' knowledge and practice. The pre-test with the control group was undertaken on the same day.
On the seventh day, the post-test was conducted with all participants in the control group, using structured knowledge questionnaires and the OSCE stations, to assess their knowledge and practice in order to evaluate the effectiveness of the skills competency programme.
The same pattern was used with the experimental group, except that the skills competency programme was administered after the pre-test. Pre-test assessments with the experimental group were started from day 2 of data collection and were spread over 3 days. Some participants took the pre-test on day 2 and were then given the skills competency programme, with the post-test taken after 7 days. The next day this was repeated with another small group of participants and again their post-test was administered 7 days after the pre-test.
Data analysis
Knowledge and practice scores were organised, tabulated and analysed using frequency distribution; descriptive statistics: mean, median, standard deviation and mean score; inferential statistics: correlation coefficient, paired and unpaired t-tests, to evaluate the effectiveness of the skills competency programme in terms of knowledge and practice.
Ethical considerations
Ethical approval (clearance) was acquired from the authors' university ethical committee. Consent was received from the authority concerned in the nursing college to conduct the study.
An informed consent form was signed by participants before data collection. It was not compulsory for nurses to be a part of the study, and they could decide to participate and leave whenever they wished. Confidentiality related to individual participants was maintained at all times.
Results
Demographic variables
Experimental group
The 40 participants in the experimental group fell into the following age groups: 21-30 years, n=32 (80%); 31-40 years, n=8 (20%); 41-50 years, n=0. The number of males was n=18 (45%) and the number of females was n=22 (55%). Regarding qualifications, n=21 (53%) nurses had the General Nursing and Midwifery (GNM) diploma and the remainder n=19 (48%) were BSc Nursing graduates. Duration of nursing experience was as follows: n=5 (13%) participants had 6 months to 1 year of experience, n=8 (20%) had 1-2 years, n=7 (18%) had 2-3 years, with n=20 (50%) having more than 3 years of work experience. With regard to specific work area, n=13 (32.5%) of the group worked in MICU, n=10 (25%) in SICU, n=5 (13%) in CCU, n=7 (18%) in neuro ICU, and n=5 (13%) in RICU.
Of the 40 nurses in this group, n=36 (90%) had administered TPN before, and n=4 (10%) had never done so. Of the nurses who had administered TPN, n=18 had done so 1-5 times, n=16 had done so 6-10 times and n=3 nurses had performed TPN more than 10 times. In terms of caring for patients with CLABSI, n=25 (63%) nurses had treated a patient with the infection before, and n=15 (38%) had not.
Control group
In the control group, participants fell into the following age groups: 21-30 years, n=25 nurses (63%), 31-40 years, n=14 (35%), with just n=1 (2.5%) in the 41-50-year age group. The number of males was n= 21 (52.5%) and the number of females was n=19 (47.5%). Regarding qualifications, n=19 nurses (48%) had the GNM diploma and n=21 (53%) were BSc Nursing graduates. Duration of nursing experience was as follows: n=6 (15%) had 6 months to 1 year of experience, n=7 (18%) had 1-2 year of experience, n=10 (25%) had 2-3 years of experience, with the largest proportion n=17 (43%) having more than 3 years' experience. With regard to specific work area, n=13 (33%) worked in MICU, n=10 (25%) in SICU, n=8 (20%) in CCU, n=5 (13%) worked in neuro ICU and n=4 (10%) in RICU. Of the control group, 37 (93%) nurses had administered TPN before; of these, n=18 (45%) had administered TPN 1-5 times, n=10 (25%) had done so 6-10 times and n=9 (23%) had performed TPN more than 10 times; n=3 (8%) had never administered TPN. Finally, in terms of caring for patients with CLABSI, 18 (45%) nurses had treated a patient with the infection and 22 (55%) had not.
Knowledge and practice of groups before and after administration of skills competency programme
Table 4 shows the findings from the structured knowledge questionnaire to assess the level of knowledge. Tables 5–9 show the scores from the four OSCE stations used to assess practice.
Table 4. Findings from structured knowledge questionnaire to assess the level of knowledge
| Level of knowledge | Experimental group (n=40) | Control group (n=40) | ||
|---|---|---|---|---|
| Pre-test | Post-test | Pre-test | Post-test | |
| Excellent knowledge (21–27) | 0 | 37 | 0 | 0 |
| Good knowledge (13–20) | 25 | 3 | 22 | 21 |
| Average knowledge (5–12) | 15 | 0 | 18 | 19 |
| Poor knowledge (<5) | 0 | 0 | 0 | 0 |
Table 5. Practice scores from OSCE station 1
| No. of items identified (total=5) | Experimental group (n=40) | Control group (n=40) | ||
|---|---|---|---|---|
| Pre-test | Post-test | Pre-test | Post-test | |
| All 5 identified | - | 27 | - | - |
| Only 4 identified | - | 12 | - | - |
| Only 3 identified | 20 | 1 | 14 | 14 |
| Only 2 identified | 12 | - | 12 | 12 |
| Only 1 identified | 4 | - | 8 | 9 |
| No item identified | 4 | - | 6 | 5 |
Table 6. Practice scores for OSCE station 2
| Level of competence based on practice score | Experimental group (n=40) | Control group (n=40) | ||
|---|---|---|---|---|
| Pre-test | Post-test | Pre-test | Post-test | |
| L4 (25–27) | 0 | 15 | 0 | 0 |
| L3 (22–24) | 0 | 23 | 3 | 1 |
| L2 (19-21) | 6 | 2 | 9 | 9 |
| L1 (≤18) | 34 | 0 | 28 | 30 |
OCSE= objective structured clinical examination; TPN=total parenteral nutrition
Table 7. Practice scores from OSCE station 3
| No. of cases assessed correctly (total=2 cases) | Experimental group (n=40) | Control group (n=40) | ||
|---|---|---|---|---|
| Pre-test | Post-test | Pre-test | Post-test | |
| Assessed both cases | 0 | 31 | 0 | 0 |
| Assessed only 1 case | 12 | 9 | 16 | 11 |
| Assessed no case | 28 | 0 | 24 | 29 |
Table 8. Practice scores from OSCE station 4
| Practice score | Experimental group (n=40) | Control group (n=40) | ||
|---|---|---|---|---|
| Pre-test | Post-test | Pre-test | Post-test | |
| Satisfactory (7–10) | 1 | 40 | 4 | 0 |
| Needs improvement (4–6) | 26 | 0 | 18 | 21 |
| Unsatisfactory (0–3) | 13 | 0 | 18 | 19 |
Table 9. Overall practice scores from all OSCE stations
| Total practice scores include all 4 OSCE stations | ||||
|---|---|---|---|---|
| Overall practice score (Total=44) | Experimental group (n=40) | Control group (n=40) | ||
| Pre-test | Post-test | Pre-test | Post-test | |
| Satisfactory practice (34–44) | 0 | 40 | 0 | 0 |
| Average practice (23–33) | 22 | 0 | 22 | 17 |
| Unsatisfactory practice (12–22) | 18 | 0 | 18 | 23 |
| Poor practice (0–11) | 0 | 0 | 0 | 0 |
Experimental group
The statistical calculations for knowledge put the paired t-value at 22.57 (degrees of freedom (df)=39, 0.05 level of significance, P=0.0001), with pre-test and post-test means of 13.6 and 23.75 respectively.
For practice, the paired t-value was calculated at 18.50 (df=39, 0.05 level of significance), with pre-test and post-test means of 22.0 and 38.9 respectively. The skills competency programme was therefore considered to have been effective.
Control group
The statistical calculations for knowledge put the paired t-value at 3.088 with pre-test and post-test means of 13.2 and 12.55 respectively (df=39 and 0.05 level of significance).
For practice, the paired t-value was calculated at 8.03 with pre-test and post-test mean of 23.55 and 21.82 respectively (df=39, P=0.05 level of significance).
Comparison
Comparison in knowledge scores of the control and experimental group showed the calculated unpaired t-value to be 22.78 at (df=39, 0.05 level of significance, P=0.0001) with post-test mean of control and experimental group being 12.55 and 23.75 respectively.
Comparison of the practice scores of the control and experimental group showed the calculated unpaired t-value to be 19.59 (df=39, 0.05 level of significance, P=0.0001) with post-test mean of control and experimental group being 21.82 and 38.9 respectively.
There was a significant difference in the knowledge and practice scores of the experimental group compared with the control group.
Correlating the knowledge and practice scores regarding prevention of CLABSI
The significance of difference in correlation at 0.05% level of significance is tested with Pearson's correlation coefficient. The results were based on the principle of correlation, ie -1 ≤ r ≤ 1.
The results show a positive correlation between knowledge and practice scores with value of the correlation coefficient being r=0.5363 in the control group and r=0.7 in the experimental group with P<0.05. In other words, there was a significant correlation between knowledge and practice scores.
Discussion
The authors believe that this study is one of a kind because few studies have been conducted based solely on CLABSI occurrence linked to TPN administration. This study has concentrated on the strengths and weaknesses of nurses to evaluate areas where more education and training are required. It has also concluded that the nurses in the study are familiar with many of the terms but lack basic knowledge and the skills necessary for accurate execution of procedures.
There are studies in the literature that reflect on the need for education and training for nurses to promote safe TPN administration and also to prevent CLABSI. Bord et al's (2020) study evaluated nursing knowledge and practice regarding TPN administration. They concluded that periodic audits to assess TPN practice, combined with knowledge assessments, are needed to improve and sustain compliance with TPN administration standards of care.
Mohapatra et al (2020) conducted a prospective study on the impact of continuous education and training in reducing the incidence of CLABSI in a neuro ICU. They pointed out that education remains an important part of hospital infection control and improves infection-control practices. Continuous teaching and training about hand hygiene practices and central-line catheter hub care were used as the intervention for this study. The quality improvement (QI) initiative achieved a 48% reduction in the CLABSI rate from the baseline rate of 8.7 to 4.5 per 1000 catheter days. The overall mortality showed a reduction in the post-intervention period. The researchers concluded that adherence to hand hygiene and catheter hub care, with continuous teaching, training and supervision, was highly effective in reducing the CLABSI rate.
Chaudhary and Rappa (2019) conducted a descriptive study to assess the knowledge of staff nurses regarding PN administration. The main findings were that 47% had a ‘good’ score for knowledge regarding PN, but there were still deficits in all areas of the knowledge assessed. For example, although the majority of staff nurses (80.8%) had good knowledge regarding concepts related to PN administration, just under one-third (32.9%) had good knowledge of the investigations required for PN administration, according to the knowledge questionnaire administered. These deficits in knowledge strongly pointed to the need for an intervention to improve the knowledge of staff nurses regarding PN administration.
Kurian and John (2016) conducted a descriptive study among staff nurses at a selected hospital in New Delhi to assess their knowledge about CLABSI. They identified that the majority (96%) of staff nurses had inadequate knowledge with only 4% found to have adequate knowledge.
A skills competency programme such as the one provided to the experimental group in the authors' study will be beneficial for critical care nurses, providing insight that even a simple procedure can cause a serious complication for the patient. Such a programme highlights that TPN administration is not just a simple procedure, but needs extra supervision and observation, and most importantly adequate knowledge and practice, to prevent a serious complication such as CLABSI.
The findings of this study have implications for nursing education, practice, administration and research. They highlight the need for improved knowledge and practice of nurses relating to TPN, especially those working in critical care units (an area where TPN is likely to be administered). Nurses are the frontline workers in healthcare institutions, which carries a great level of responsibility. Critical care nurses should have adequate knowledge regarding TPN, its formulation and preparation, administration and monitoring, and TPN-associated complications. Moreover, critical care nurses should also be knowledgeable regarding CLABSI as one of the most common and serious complications of TPN administration.
With improvements in knowledge, practice is also improved. The present study not only aimed to improve the knowledge, but also the practice of critical care nurses regarding the prevention of CLABSI linked to TPN administration, through the delivery of a skills competency programme and the use of modified practice checklists for procedures used in the OSCE stations to assess skills. The practice checklists helped assess the inadequacies in the practice of the critical care nurses, but also gave a clear picture of the areas where improvement is needed. These checklists can therefore be used not only to assess the level of practice of critical care nurses but also to guide them through the steps of the procedures correctly. The findings of the present study can be beneficial in helping to improve the practice skills and competency of nurses in their clinical settings.
Nurse administrators play a vital role in organising and directing learning opportunities for critical care nurses, through the provision of educational programmes. Therefore, the outcomes of the present study can help nursing administrators assess the understanding and practice of their nurses, and guide them on the provision of appropriate education, such as skills competency programmes, in order to improve the knowledge and skills of nurses working in various clinical settings.
Limitations
Increasing numbers of COVID-19 cases at the time this study was carried out meant it was difficult to conduct it smoothly. Data collection was difficult at times, because critical care nurses had different shifts and they only had limited time to participate in the present study. The relatively small sample limits the generalisation of the findings.
Conclusion
The critical care nurses in this study had some existing knowledge regarding TPN, certain aspects of CLABSI and CVC care and maintenance, but this knowledge required improvement because the majority of the critical care nurses had inadequate knowledge regarding the prevention of CLABSI due to TPN administration. The critical care nurses showed competence in their practice to some extent but the majority of the participants required improvement and there was a risk of patients developing CLABSI and other TPN-related complications, as indicated by the ‘red flag’ scores.
The skills competency programme regarding prevention of CLABSI due to TPN administration was effective because it significantly improved the knowledge and practice scores of the critical care nurses, as shown in the comparison of the post-test knowledge and practice scores for the control and experimental groups.
KEY POINTS
- Central-line associated bloodstream infection (CLABSI) is a serious complication of total parental nutrition (TPN) administration
- It is important that nurses working in critical care are aware of the link between TPN and CLABSI and the steps that should be taken to prevent this complication
- This study looked at an initiative to improve nurses' knowledge and practice to prevent complications of TPN administration, especially CLABSI
- The skills competency programme and checklists used in the study provide a possible model for future education and training efforts
CPD reflective questions
- Most instances of CLABSI occur in patients receiving parenteral nutrition therapy. Reflect on the potential weaknesses in nursing practice when providing care for such patients
- What training opportunities are in place in your organisation to support safe TPN administration?
- Are you aware of the different standards and guidelines regarding safe TPN administration and CLABSI prevention developed by organisations and societies? Which ones are followed in your place of work and why?