Abstract

OBJECTIVES: To investigate the knowledge, attitude, and practice regarding sterilization among CSSD staff working in Saudi MOH hospitals. STUDY DESIGN: cross-sectional study. METHODOLOGY: This study carried over 5 months (Dec 2020 - Apr 2021) targeted 371 CSSD working staff who are directly involved in reprocessing surgical instruments and medical equipment in the Saudi MOH Hospitals in all regions. Data collected by self-administered questionnaire consisting of personal information, work characteristics and the Knowledge Attitude and practice scale (KAP). RESULTS: MOST CSSD staff, either Specialized in CSSD or not, have sufficient knowledge regarding sterilization techniques. A positive correlation exists between knowledge-attitude, knowledge-practice and attitude-practice. It has been found some significate correlations between two of the study variables and the knowledge, attitude, and practice of the study population. As expected there was a relationship between Specialty in sterilization and knowledge, but surprisingly, there was no relationship with practice and attitude. Also, there was a relationship between practice, attitude, and years of experience, But no relationship with knowledge. CONCLUSION: CSSD staff in Saudi MOH hospitals show very good knowledge and are having a high positive attitude towards the use of sterilization techniques, and are efficiently practicing the sterilization techniques.

1. Introduction

Health care institutions should make all efforts on infection prevention and control; to enhance a safe health care environment for both patients and healthcare providers, where the low rate of Healthcare-Associated Infection (HAI) is considered one indicator of successful healthcare services ^{1, 2}. According to the World Health Organization (WHO), HAI one of the critical issues faced by hospitals and has a significant impact on patient safety. It led to health problems and contributed to social losses, prolonged hospital stays, long-term disability, increased resistance to antimicrobial agents, high morbidity, additional financial burden, and excess mortality. In 2013, the percentage of HAI around all hospitals globally reached 9%, where more than 1.4 million hospitalized patients have acquired the infection ^{2, 3}. "HAI" can be defined as infections that originated or occur in hospitals and usually arise within 48 hours after being admitted to the hospital for up to 30 days ². Healthcare workers (HCWs) are at an increased risk of cross-infection while practicing the sterilization process ¹. Patients receiving medical services in hospitals, either during surgery or in hospital admissions, face the risk of infection also ². There are a high possibility of blood-borne diseases, contagious respiratory and other illnesses spread, mainly through the preparation of non-sterile medical devices and instruments that is usually used in direct contact with the wound and the body's biological fluids ^{1, 2}. Body fluids can be highly infectious if the correct precaution has not been followed inside the central sterile supply department (CSSD) ⁴.

CSSD is a strategic service unit that contributes to preventing HAI in health institutions. CSSD is where the quality standards of sterilization and disinfection are maintained, and the acceptance and distribution of all tools or instruments that require sterile conditions for clinical medical activity ². Sterilization is a process of the destruction or killing of all microorganisms, including bacterial spores. Disinfection is the destruction of not all microbial types but most recognized pathogenic and other types of microorganisms by using heat or chemical material ¹. The introduction of adequate medical sterilization services is one of the critical infection prevention protocols and universal precautions for hospitals and surgical operators to avoid cross-contamination and suppress HAI. Moreover, by the correct handling of surgical instruments and how to reprocess medical devices appropriately, sterilization process plays an essential role in reducing the manufacturing of numerous amounts of surgical instruments ⁵.

In recent years, the Saudi Commission for Health Specialties (SCFHS) has introduced a medical sterilization program with a medical sterilization specialist certification. This opportunity contributed to the graduation of sterilization specialists to work at the CSSD in both MOH hospitals and private hospitals. Sterilization specialists and technicians do the same work but with different educational levels and qualifications. Specialists obtained a high diploma from the SCFHS after their bachelor's degree. Technicians do not have the same adequate education level as specialists ⁶. Besides, some of the backgrounds of CSSD staff are not related to the sterilization field (e.g. Figure 1 and Figure 2).

Therefore, this paper aimed to investigate the knowledge, attitude, and practice regarding sterilization among CSSD staff working in Saudi MOH hospitals.

2. Methods

Study Design and setting: This is a cross-sectional study carried over 5 months from Dec 2020 till Apr 2021 targeted all CSSD working staff who are directly involved in reprocessing surgical instruments and medical equipment in the Saudi MOH Hospitals in all regions.

Sample Size: A sample of (371) CSSD staff working on all Saudi MOH hospitals generated by using open epi software version 3, with a 1744 total population size of the MOH hospitals' CSSD staffs, a 97% confidence level, and 50% anticipated frequency of outcome factor in the population.

Data Collection tools and procedure: A self-administered questionnaire consisting of close-ended questions has been used and collected through an online survey. The questionnaire includes three sections; the first part involves personal information of the participants, such as; Region, Age, Gender, nationality. Second part work characteristics such as; weekly working hours, years of experience, administrative responsibility, type of working shifts, and Job title. The third part was the Knowledge Attitude and practice scale (KAP) that contained 33 validated questions covering all three standards; Knowledge (with 14 items), Attitude (with 9 items), and Practice (with 10 items). A pilot study among 32 CSSD staff has conducted and later on, they have excluded from the main study sample. Likert scales used to assess the level of Knowledge Attitude and practice ranked as; Knowledge [K1-K14]: (4-Yes, very well, 3-Yes, well, 2- Yes, to some extent, 1-No). Attitude [A1 & A7]: (1-Strongly agree, 2- Agree, 3- Neutral, 4-Disagree).

[A2-A6 & A8-A9]: (4-Strongly agree, 3- Agree, 2- Neutral, 1-Disagree). Practice[P1-P2 & P4-P10]: (4- Always, 3-Most of the time, 2- Sometimes, 1- Rare).

[P3]: (4- Sometimes, 3- Rare, 2-Most of the time, 1- Always).

Statistical Analysis: Data analyzed using the Statistical Package for Social Sciences (SPSS) version 26, descriptive statistics tables with frequency, percentage, mean, p-value, and standard deviation have been used. Besides, the Chi-square test, analysis of variance (ANOVA), and Kendall’s test have been used to compare variables and study correlation.

Ethical Consideration: Informed Consent has presented before answering the questionnaire. Participants' identities were kept anonymously. Approval has been obtained from the ethical review board at King Fahad Medical City research center (IRB Log Number: 21-0069E).

3. Result

The study response rate reached more than 100% with a total of 377 responses. The job title and specialty of the study population are shown in Figures 1 and 2. Only less than half of the subjects were specialized in sterilization (36%). Most of the respondents were health technicians (72%).

Out of a total of 377 CSSD Staff included in our study, 222 were female and 155 males. In addition, most of them were in the age group 31-40 years (62.6%). Further, 84.6% of the subjects were Saudi, and the majority of the population worked for 23-47 hours/week (61.0%). Also, most of the subjects had an experience of less than 10 years (63.1%). More than half of the study subjects had no other administrative tasks (59.2%). Finally, most CSSD staff worked in fixed shifts (50.9%), and more than half had no night shift work (67.1%). Further analysis of results showed significant differences between sterilization specialty and gender, Age, Nationality, Years of experience, administrative task, type of working shifts, and night shifts. Females with sterilization specialty were higher than males (69.6%). Sterilization specialty among staff in the age range of 31-40 years was greater compared to other age groups (63.7%). Saudi staff with sterilization specialty were higher than non-Saudi staff (92.6%). Sterilization specialty among those who had less than 10 years of experience were the highest (76.3%). Among the staff, those who had no administrative tasks, who work in rotating shifts, and who work night shifts show the highest in sterilization specialty (68.1%, 72.6%, 52,6) Table 1. Table 2, Table 3, Table 4 show an overview of Study Population Knowledge, Practice, and Attitude towards Sterilization.

Among the knowledge questions table present, it was observed that knowledge regarding the proper method of hand hygiene could be labeled as good knowledge (84%). Most of those surveyed indicated that they have adequate knowledge about wearing PPE accurately and follow the standard precaution while handling contaminated instruments (83%). Just over half reported that they have a sufficient understanding of operating the equipment’s machines in the right way (78%). Pre-cleaning and the principle of manual cleaning were familiar to most study subjects (83%-75%). Other responses on the knowledge section, show us a good understanding of the usage of a spill kit, differences between the rigid scope, semi-rigid scope and flexible scope, usage of a tracking system, differences between thermal and chemical disinfection, differences between packaging technique, Spaulding classification, differences between steam sterilization and low-temperature sterilization, usage of chemical/biological indicators Table 2.

The results of the practice questions are shown in Table 3. The overall answer to these questions is very positive. The answers give us a good impression of correct practice among the CSSD staff. It shows that following manufacturer instructions for reusable medical devices, and apply biohazard signs during dirty transportation is followed properly among CSSD staff. However, it has been shown that most study subjects did not use lubrication properly. Moreover, results show good practice among CSSD staff regard: performing manual cleaning before loading the instrument inside the washer-disinfector, routine validation test for the machine, and an inspection of reusable medical devices after unloading from the washer-disinfector. The practice of study population was good regarding applying sterilizer test regularly before operation (leak test, Bowie-Dick test, BI), checking the sterilizer parameters and allowing instruments to cool down after unloading from the sterilizer.

Table 4 shows an overview of the attitude responses section; most of the staff show positive attitude regard applying hand wash before and after entering the work area, arrange reusable medical devices in an orderly fashion way, how to deal with sharp tools, using spill kit, disassembly of reusable medical devices during cleaning, follow proper consequences for donning and doffing PPE, and applying validations test for sterilizer. Yet, 73% agree that they should dry instrument after manual cleaning.

A significant correlation was seen between knowledge-attitude, knowledge-practice and attitude-practice (p value =0.000, p≤0.01) Table 5.

Table 6 and Table 7 presents mean knowledge, attitudes, and practice scores of both variables (Sterilization Specialty and Years of Experience). Significant correlation between Sterilization Specialty and means of knowledge (.000). Also, between Years of Experience and means of both attitudes and practice scores (.000, 0.002). No differences were noted for means of attitude and practice scores in sterilization specialty and knowledge with years of experience.

4. Discussion

In this study, the topic under discussion is the level of knowledge, attitudes, and practices among CSSD staff in Saudi MOH Hospitals. This study is special because it is the first time to be conducted among the subjects under study. Based on previous study, the quality of patient care and patient safety can be determined by the level of knowledge of HCWs ³.

According to our findings, most CSSD staff, either Specialized in sterilization or not, have sufficient knowledge regarding sterilization techniques. Data report that there is no much difference between staff specialized in sterilization or not. A positive correlation exists between knowledge-attitude، knowledge-practice and attitude-practice Table 5. It has been found some significate correlations between two of the study variables and the knowledge, attitude, and practice of the study population. As expected there was a relationship between sterilization specialty and knowledge, but surprisingly, there was no relationship with practice and attitude. Also, there was a relationship between practice, attitude, and years of experience, but no relationship with knowledge.

Attributable reasons for these findings could be due to how the newly graduated staff has a better education than those who have been working a long time ago and did not have the same chance of education. Especially, now as the SCFHS has graduated many Saudi females sterilization specialists during the past three years. A good education could help the recent graduates demonstrating a good level of knowledge but not regarding attitude and practice where it can be gain by experience.

Another reason could contribute to this high knowledge level. More than half of the study subjects had no other administrative tasks and almost half of them worked fixed shifts and more than half had no night shift work. Having no administrative tasks, no night shift and rotating shifts at work could give the staff time and chance to get familiar with all surgical instruments and the method of reprocessing varied surgical instruments and therefore gains more experience and knowledge. Where the night shift due to little work and not encounter many working in different surgical instruments could lead to not acquiring new experiences and therefore less knowledge. And the administrative tasks and fixed shifts will reduce the staff chance from getting enough time and working on different tasks.

In previous studies, It is recommended that only washing hand HCWs can prevent approximately 40-45% of the HAI which is reasonably a high success rate ³. In this regard, one of the noticeable findings of our study is the sufficient knowledge and positive practices on this essential point in standard precaution: hand hygiene that plays a vital role in breaking the chain of infection (Table 2 and Table 3).

Previous study have reported that HCWs, have to receive instructions on how to adhere to safety in the workplace ⁷. To achieve high compliance in infection control practices by the good sterilization practice, the focus should be given to good-quality training of HCWs regularly. It should be made mandatory for hospitals to get their HCWs trained from accredited training centers; not only for one-time but should be a continuous training process. And also, to improve overall knowledge and practice related to sterilization, strict implementation of sterilization policy should be taken ¹. Another important area in improving sterilization in Saudi Arabia is considering that there has never been a proper establishment of sterilization specialty in Saudi Arabia universities, it must be added on as bachelors or diploma degree to graduate well-educated staff in the field working on the CSSD.

The results of this study are discussed bearing in mind one limitation. There might be some poor phrasing in the questions, which might give clues to the respondents and therefore influence the response.

5. Conclusion

Finally, CSSD staff in Saudi MOH hospitals show very good knowledge and are having a high positive attitude towards the use of sterilization techniques, and are efficiently practicing the sterilization techniques. Yet, there is no studies have been done in Saudi Arabia state the importance of the level of sterilization knowledge in infections prevention and control. More studies in this area should be implemented to address all hospitals type not just restricted to MOH hospitals. Including all CSSD Staff in Saudi Arabia to generalize outcomes at a larger level, this might give a clearer idea for knowledge, attitudes, and practices among CSSD staff and help to improve the prevention of infections and control in all Saudi Hospitals.

Acknowledgements

We would like to express our gratitude to Arwa Shesha, Hanan Hathout, Abdulmajid Almutairi, Tabish Humayun and Aisha Al Shehri for thier support and advisement on this work.

References