JHS. Official Publication of The Saudi Commission for Health Specialties. July 2016 / Volume 4 / Issue 3 ISSN X.

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1 ISSN X July 2016 / Volume 4 / Issue 3 Journal of Health Specialties JHS Official Publication of The Saudi Commission for Health Specialties

2 Original Article Invasive haemodynamic monitoring at critical care units in Sudan: Assessment of nurses performance Waled Amen Mohammed Ahmed 1, Mudathir MohammedAhmed Eltayeb 2, Nahed Abd-Elazeem Abd-Elsalam 3 1 Department of Nursing, Faculty of Applied Medical Sciences, Albaha University, Al-Baha, Saudi Arabia, 2 Department of Medical-Surgical and Critical Care Nursing, National University, Khartoum, Sudan, 3 Department of Community Health Nursing, Faculty of Nursing, Port Said University, Port Said, Egypt ABSTRACT Background: Invasive haemodynamic monitoring is one of the major competencies required for critical care nurses. Critically ill patients need continuous assessment of their cardiovascular system to diagnose and manage complex medical conditions. Aim: This study aimed to assess critical care nurses knowledge and practice of invasive haemodynamic monitoring in Khartoum government hospitals. Materials and Methods: A descriptive study was conducted. It included ninety critical care nurses who worked in the Intensive Care Units (ICUs) of Khartoum government hospitals that have invasive haemodynamic monitoring system. The study extended from March 2013 to April Data were collected from ninety critical care nurses working in selected ICUs; using a validated questionnaire. The data were analysed by the Statistical Package for Social Services Version 20. Results: The results showed that availability of written protocols regarding invasive haemodynamic monitoring within ICUs was low (34.3%). The overall knowledge of critical care nurses (who participated in the study) about invasive haemodynamic monitoring was not acceptable. The results also showed that the estimated total practice of the registered nurses who participated in the study was either fair (75.6%) or poor (24.4%). This study indicated that critical care nurses knowledge was poor to fair and that of registered nurses practice was poor. Conclusion: The study showed unacceptable level of nurses knowledge on haemodynamic monitoring. The nurses practice about was poor. Keywords: Critical care nurses, haemodynamic monitoring, knowledge, practice INTRODUCTION Monitoring is considered to be one of the most important aspects of nurses role within Intensive Care Address for correspondence: Dr. Waled Amen Mohammed Ahmed, Department of Nursing, Faculty of Applied Medical Sciences, Albaha University, P. O. Box: 1988, Al Baha, Saudi Arabia. E mail: weliameen1980@yahoo.com Quick Response Code: Access this article online Website: Units (ICUs). [1] On going monitoring is crucial to review the patient s needs and assess the effectiveness of the care that a patient receives. [1] Invasive haemodynamic monitoring is one of the major competencies required for critical care nurses. Moreover, monitoring parameters and assurance of accuracy of an invasive system are crucial in providing high quality nursing care in the ICUs. [2] This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact: reprints@medknow.com DOI: / How to cite this article: Ahmed WA, Eltayeb MM, Abd-Elsalam NA. Invasive haemodynamic monitoring at critical care units in Sudan: Assessment of nurses performance. J Health Spec 2016;4: Journal of Health Specialties Published by Wolters Kluwer - Medknow

3 The mistakes, false readings as well as malfunctioning of the monitoring system will directly affect the patient s actual monitoring, negatively impacting the pathway of the patient s whole care plan. These events may also lead to hazards or put the patient at a higher risk of wrong interventions, especially that of cardiovascular system which is one of the most important systems that needs close monitoring because of its importance in providing perfusion to the entire body, especially the brain, heart and kidneys. [1] International and national job duties of ICU nurses obligate them to tackle the haemodynamic monitoring. Evidences also shows that taking care of haemodynamic monitoring needs specific competencies in knowledge and practice. [3] Studies repeatedly have shown that physicians and nurses lack enough knowledge of the principles of measurements. Moreover, the improper position for measurement on the actual waveform can also be a source of error. [4] The literature on nurses knowledge of invasive haemodynamic monitoring is limited, but many studies, [5 8] conducted among nurses, indicate a knowledge deficit in invasive pulmonary artery pressure (PAP) monitoring. No traced studies were conducted in Sudan investigating the nurses role in haemodynamic monitoring; thus, the aim of this study was to evaluate critical care nurses knowledge and practice about invasive haemodynamic monitoring in governmental hospitals ICUs in Khartoum (which is the capital of Sudan and contains the largest number of ICUs in the country). MATERIALS AND METHODS This is a descriptive study aimed to assess critical care nurses knowledge and practice regarding invasive haemodynamic monitoring. It was conducted at all governmental hospitals in Khartoum State that have invasive haemodynamic monitoring at their ICUs (Sudan Heart Institute, Ahmed Gasim Specialized Hospital and Shaab Teaching Hospital). The population of this study consisted of all nurses who work in the governmental hospitals ICUs invasive haemodynamic monitoring system in Khartoum State. All critical care nurses in the study areas were included in the study. The participation in the study was confirmed post agreement. The study excluded the nurses who were not registered in the Sudanese National Medical and Health Professional Council, and those who refused to participate in the study. It included ninety critical care nurses, traced during data collection period by convenience sampling technique. Ethical approval was obtained from the National Ribat University, Faculty of Graduate Studies and Scientific Research. Permissions from the administration of Sudan Heart Institute, Ahmed Gasim Specialized Hospital and Shaab Teaching Hospital were obtained. The right of the participants to withdraw at any time was explained and preserved during the study. The data on nurses performance were collected using two tools; the structured questionnaire and observational checklist. The questionnaire included responses to questions; correct responses scored one and incorrect responses scored zero. The total score for each participant was calculated. An average for the correct responses and incorrect responses were then calculated. The questionnaire was tested and validated before starting the study. Cronbach s alpha was 0.82, which was above the acceptable level. The observational checklist included responses to questions; correct responses scored one and incorrect responses scored zero. The total score for each participant was calculated. An average for the correct responses and incorrect responses were then calculated. The checklist was tested and validated before starting the study. Cronbach s alpha was 0.76, which was above the acceptable level. The questionnaire was used to assess the general demographic characteristics of the study subjects. It included questions related to the general characteristics such as the years of experience, attendance of invasive haemodynamic monitoring courses, availability of written protocols in their ICUs, and assessment of nurse s knowledge regarding variables of invasive haemodynamic monitoring including questions about knowledge related to phlebostatic axis, central line removal position, etc. The observational checklist was used to assess the practical performance of nurses on invasive haemodynamic monitoring. The collected data were cleaned at the data collection field, organised into a master sheet and then entered into the computer, using the software, Statistical Package for Social Science version 20 (IBM Corp., Armonk, New York, USA), to be analysed. All variables were displayed as frequency tables, charts and graphs; then Chi square test (cross tabulation) and model logistic regression were performed test the significance of relationships between demographic variables and nurses knowledge and practice, where only values 0.05 were considered statistically significant. The results were presented with P value and confidence intervals. Journal of Health Specialties / July 2016 / Vol 4 Issue 3 197

4 RESULTS Seventy-eight (86.7%) of the registered nurses had a bachelor s degree, out of which 65 (72.2%) having not attended intensive haemodynamic courses. Their experiences ranged between 1 and 9 years and their main source of knowledge was through senior colleagues by 61 (67.8%) [Table 1]. Table 2 shows that registered nurses knowledge about the need for preparation of invasive haemodynamic monitoring was 67 (74.4%), majority of them did not know Allen test, 76 (84.4%) and only 5 (5.6%) of them do not know preparation of central line insertion. Table 3 showed that 88 (97.8%) of registered nurses mentioned the need for invasive haemodynamic Table 1: Demographic titles of distribution of critical care nurses in Intensive Care Units, 2014 Variable total (n=90) n (%) Qualification Diploma 2 (2.2) Bachelor 78 (86.7) Master 10 (11.1) Availability of protocols Yes 31 (34.4) No 59 (65.6) Source of knowledge Written protocol 23 (25.6) Senior colleague 61 (67.8) Internet 4 (4.4) Mass media 2 (2.2) Attended invasive haemodynamic courses Yes 25 (27.8) No 65 (72.2) Experience (in years) Mean 4.82 SD 3.48 Minimum 1 Maximum 9 SD: Standard deviation Table 2: Critical care nurses knowledge about preparation of invasive haemodynamic monitoring in Intensive Care Units, Sudan, 2014 Variable total (n = 90) n (%) Knowledge about needed equipment for IHDM Correct (arterial line, transducer, connecting cables, a monitor, 67 (74.4) pressure bag with solution) Incorrect 23 (25.6) Knowledge about meaning of Allen test Correct (arterial collateral perfusion) 14 (15.6) Incorrect 76 (84.4) Knowledge about the need for preparation of central line insertion Correct (central venous catheter kit) 85 (94.4) Incorrect 5 (5.6) IHDM: Invasive haemodynamic monitoring monitoring (IHDM) is arterial blood pressure (ABP), 88 (97.8%) said central venous pressure (CVP) is indicated and 54 (60.0%) said PAP is also indicated. Table 4 showed that majority of registered nurses did not know the correct line for CVP monitoring connection, 68 (75.6%), whereas 50 (55.6%) of them knew the correct pressure in the pressure bag. Table 5 shows that 72 (80%) registered nurses could do a good troubleshooting when BP shoots, 64 (71.1%) of them also did a good troubleshooting when BP dropped. There were 82 (91.1%) of nurses unsure if the level of the transducer affects the actual reading, and only 13 (14.4%) of them knew the accurate atmospheric pressure value. Table 6 shows that the registered nurses who are able to ensure that the pressure bag is well functioning were 64 (71.1%); 63 (70%) of them knew the CVP indications and only 52 (57.8%) of them knew the ABP indications. In addition, only 15 (16.7%) of them knew the best position for removing a central line. Table 7 shows that registered nurses who explained the procedure to patients as practice were ninety (100%), also ninety (100%) of them assisted with positioning Table 3: Critical care nurses knowledge about the indications for invasive haemodynamic monitoring in Intensive Care Units Sudan, 2014 The needs of IHDM Frequency (%) Yes No IHDM is needed for measuring invasive blood pressure 88 (97.8) 2 (2.2) IHDM is needed for measuring non invasive blood 21 (23.3) 69 (76.7) pressure IHDM is needed for measuring electrocardiogram 40 (44.4) 50 (55.6) IHDM is needed for measuring central venous pressure 88 (97.8) 2 (2.2) IHDM is needed for measuring pulmonary artery pressure 54 (60.0) 36 (40.0) IHDM is needed for measuring temperature 31 (34.4) 59 (65.6) IHDM is needed for measuring heart rate 42 (46.7) 48 (53.3) IHDM: Invasive haemodynamic monitoring Table 4: Nurses knowledge about connection and securing invasive haemodynamic monitoring in Intensive Care Units, 2014 Variable total (n = 90) (n=90) (%) The best central venous pressure line connection Correct (distal line) 22 (24.4) Wrong (proximal and median) 68 (75.6) The pressure in the pressure bag should be Correct (300 mmhg) 50 (55.6) Wrong (50, 100, 200, and 400 mmhg) 40 (44.4) Making regular flushing every Correct (h) 48 (53.3) Wrong (1.5, 2, 5, 10 min) 42 (46.7) Phlebostatic axis knowledge Correct (point of levelling transducer) 35 (38.9) Wrong (other) 55 (61.1) 198 Journal of Health Specialties / July 2016 / Vol 4 Issue 3

5 Table 5: Nurses knowledge about calibration, zeroing, and troubleshooting the system of invasive haemodynamic monitoring in Intensive Care Units, 2014 Variable total (n=90) n (%) Calibration of the system should be: At least every shift 32 (35.6) Wrong 58 (64.4) The first thing to do for a shooting blood pressure is to Notify the physician 12 (13.3) Start sodium nitroglycerine infusion 6 (6.7) Check the system first 72 (80) The first thing to do for a dropping blood pressure is to Notify the physician 5 (5.6) Start fast flush infusion 21 (23.3) Check the system first 64 (71.1) Confirmation of the actual parameter is confirmed by Physician 19 (21.1) Checking the system 42 (46.7) Making calibration 28 (31.1) Do nothing 1 (1.1) Repeated zeroing is important in the recognition of the accurate reading Yes 38 (42.2) No 52 (57.8) The level of the transducer affects the actual reading Yes 82 (91.1) No 8 (8.9) The atmospheric pressure at the sea level is 0 46 (51.1) (8.9) (14.4) Do not know 23 (25.6) Table 6: Nurses knowledge about the ability to differentiate between true and false readings of invasive haemodynamic monitoring in Intensive Care Units, 2014 Variable total (n = 90) n (%) To ensure the pressure bag is well functioning you test it by Zeroing the transducer 23 (25.6) Pressing the flushing device 64 (71.1) Notify the physician 2 (2.2) Do nothing 1 (1.1) Central venous pressure is indicated to measure the afterload Yes 63 (70) No 27 (30) Invasive blood pressure is indicated to measure the preload Yes 52 (57.8) No 48 (42.2) The best position of removing the central line Correct (Trendelenburg) 15 (16.7) Wrong 75 (83.3) the patient, but only 13 (14.4%) of them did Allen test as preparation. Table 8 shows registered nurses who prepared the system before puncturing the patient as 67 (74.4%), Table 7: Nurses preparation for haemodynamic monitoring in Intensive Care Units, 2014 Observation Frequency (%) Done Not done Explained the procedure to the patient 90 (100) 0 (0) Assisted in the positioning of the patient 90 (100) 0 (0) Performed Allen test 13 (14.4) 77 (85.6) Table 8: Nurses practice about close system sampling for invasive haemodynamic monitoring in Intensive Care Units, 2014 Observation Frequency (%) Total Done Not done Preparation of the system before puncturing 67 (74.40) 23 (25.60) 90 Zeroing of the system before connection 31 (34.40) 59 (65.60) 90 Preparing of the plasters, catheter, gloves 87 (96.70) 3 (3.30) 90 Sterile dressing set ready 85 (94.40) 5 (5.60) 90 preparing of the plasters, catheters and gloves before puncturing as 87 (96.7%), and those who prepared a sterile dressing set ready before as 85 (94.4%) [Figures 1 and 2]. DISCUSSION The measurement of haemodynamic monitoring among critically ill patients is essential. Inaccurate measurement may create risks and mistakes in diagnosis as well as nursing and medical interventions. [9] Invasive haemodynamic monitoring is an expensive technique, and time consuming for nurses, which mainly involves ensuring proper monitoring for critically ill patients. This study reflected that the total knowledge of nurses was either fair or poor, and their total practice percentage was mainly fair. The findings of our study were similar to findings reported by a pilot study conducted in two university affiliated hospitals, which showed that most nurses (83.9%) did direct ABP monitoring. The mean score of knowledge in the pilot findings was 36.7%. [10] In contrast to these results elicited from this study, a study conducted on invasive intravascular haemodynamic monitoring technical issues, showed that physicians and nurses did not have a strong knowledge of the principles of measurements and key factors in the use of transducers namely zeroing, levelling and calibrating. An understanding of the concept of transmural pressure is the key to avoid many potential artefacts related to variations in pleural pressure. [4] With an inaccurate preparation of monitoring system, all measured haemodynamic indices would be inaccurate; therefore, causing the entire haemodynamic monitoring to be erroneous. Regarding preparation of IHDM, total knowledge in preparation was good. Regarding connection and securing of the system, about one quarter of nurses know how to connect the Journal of Health Specialties / July 2016 / Vol 4 Issue 3 199

6 Figure 2: Nurses total invasive haemodynamic monitoring practice in Intensive Care Units, 2014 Figure 1: Nurses overall knowledge about invasive haemodynamic monitoring in Intensive Care Units, 2014 CVP line to the correct line, half of them knew the correct pressure of the pressure bag but most of them did not know the Allen test. The nurses practice in this study was similar to findings of a study conducted in North America on haemodynamic monitoring in post anaesthesia care units to evaluate nurses skill and knowledge base in invasive haemodynamic monitoring, which showed that nurses lacked skills concerning invasive haemodynamic monitoring. [11] Regarding knowledge on calibration, levelling and troubleshooting; only 35.6% knew the ideal intervals of zeroing the system, 91.1% knew that the level of transducer affected the actual reading, 46.7% knew the correct confirmation of the actual parameters and only 14.4% knew the correct atmospheric pressure. The effect of qualification, years of experience, undergone courses, source of knowledge and availability of protocol are not statistically significant on the level of registered nurses knowledge since P values are more than This is compared to a study made in Calabria region of Italy in 2013, which demonstrated that written policies, formal training and years of experience contributed to an increase in knowledge, practice and positive attitude toward central line associated bloodstream infection prevention. [12] Regarding assessment of registered nurses practice about preparation of IHDM; all critical care nurses explained the procedure to patients, assisted in the positioning of patients but only a few of them could perform the Allen test. These findings reflected acceptable level of knowledge. Regarding practice of close system sampling, there was no nurse who performed the correct way of sampling, and 93.3% followed the aseptic technique, 0.0% changed the stoppers of the three way and also 0.0% checked the status of the three way stopcock. The present study is unique in several ways. Firstly, the type of assessment, which includes knowledge and practice in a very critical area. Secondly, the area of the study, which were ICUs in an undeveloped country. Thirdly, this research identified key determinants of nurses knowledge and practices, rather than simply documenting what nurses did and what demographic factors related to these knowledge and practices. The findings of the study have implications that could increase nurses knowledge and practice on invasive haemodynamic monitoring. The shortcomings of this study are that it was done in a developing country that is lacking previous or similar studies as compared to the developed countries which have written statistics and database. The results can be considered a database toward nursing care for invasive haemodynamic monitoring patients in ICUs, not only in Sudan but also in developing countries with similar situations. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. REFERENCES 1. Michael JA, Papadakos JP. Approach to intravascular access and hemodynamic monitoring. The Intensive Care Manual. New York: The McGraw Hill Companies; p Polderman KH, Girbes AR. Central venous catheter use. Part (1): Mechanical complications. Intensive Care Med 2013;21: Linda DU, Kathleen SM, Mary EL. Thelan s Critical Care Nursing, Diagnostic and Management, Hemodynamic 200 Journal of Health Specialties / July 2016 / Vol 4 Issue 3

7 Monitoring. 5 th ed. Mosby Inc: Saint Louis, Missouri, USA;2006. p Magder S. Invasive intravascular hemodynamic monitoring: Technical issues. Crit Care Clin 2007;23: Bridges EJ. Evaluation of critical care nurses knowledge and ability to utilize information related to pulmonary artery pressure measurement. DTIC Document; Kondrat P. Critical Care Nurses Knowledge of Pressure Waveforms Obtained From the Pulmonary Artery Catheter [Master s Thesis]. Seattle, Wash: University of Washington; Burns D, Burns D, Shively M. Critical care nurses knowledge of pulmonary artery catheters. Am J Crit Care 1996;5: Iberti TJ, Daily EK, Leibowitz AB, Schecter CB, Fischer EP, Silverstein JH. Assessment of critical care nurses knowledge of the pulmonary artery catheter. The Pulmonary Artery Catheter Study Group. Crit Care Med 1994;22: McGhee BH, Bridges EJ. Monitoring arterial blood pressure: What you may not know. Crit Care Nurse 2002;22: McGhee BH, Woods SL. Critical care nurses knowledge of arterial pressure monitoring. Am J Crit Care 2001;10: Labeau SO, Vandijck DM, Rello J, Adam S, Rosa A, Wenisch C, et al. Centers for disease control and prevention guidelines for preventing central venous catheter related infection: Results of a knowledge test among 3405 European intensive care nurses. Crit Care Med 2009;37: Bianco A, Coscarelli P, Nobile CG, Pileggi C, Pavia M. The reduction of risk in central line associated bloodstream infections: Knowledge, attitudes, and evidence based practices in health care workers. Am J Infect Control 2013;41: Author Help: Online submission of the manuscripts Articles can be submitted online from For online submission, the articles should be prepared in two files (first page file and article file). Images should be submitted separately. 1) First Page File: Prepare the title page, covering letter, acknowledgement etc. using a word processor program. All information related to your identity should be included here. Use text/rtf/doc/pdf files. Do not zip the files. 2) Article File: The main text of the article, beginning with the Abstract to References (including tables) should be in this file. Do not include any information (such as acknowledgement, your names in page headers etc.) in this file. Use text/rtf/doc/pdf files. Do not zip the files. Limit the file size to 1 MB. Do not incorporate images in the file. If file size is large, graphs can be submitted separately as images, without their being incorporated in the article file. This will reduce the size of the file. 3) Images: Submit good quality color images. Each image should be less than 4096 kb (4 MB) in size. The size of the image can be reduced by decreasing the actual height and width of the images (keep up to about 6 inches and up to about 1800 x 1200 pixels). JPEG is the most suitable file format. The image quality should be good enough to judge the scientific value of the image. For the purpose of printing, always retain a good quality, high resolution image. This high resolution image should be sent to the editorial office at the time of sending a revised article. 4) Legends: Legends for the figures/images should be included at the end of the article file. Journal of Health Specialties / July 2016 / Vol 4 Issue 3 201