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Infection, Disease & Health xxx (xxxx) xxx

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: http://www.journals.elsevier.com/infection-

disease-and-health/

Research paper

Infection prevention and control in computed

tomography: creating a national survey
Suzanne Hill, Yobelli A. Jimenez, Dania Abu Awwad, Sarah J. Lewis*

Discipline of Medical Imaging Sciences, Faculty of Medicine and Health, The University of Sydney. 1 Science Road,
Camperdown, NSW, 2006, Australia

Received 5 March 2023; received in revised form 15 August 2023; accepted 22 August 2023

KEYWORDS Abstract Background: Infection prevention and control (IPC) is essential for quality health-
Infection prevention care, with healthcare associated infections (HAI) a known risk to patients requiring medical im-
and control; aging (MI). To date, few papers have adopted a national approach to understanding or
Computed benchmarking the knowledge of, attitudes toward, and practice (KAP) of IPC in the context
tomography; of MI and no validated surveys or scales are identified in the literature. The Computed Tomog-
Knowledge; raphy (CT) suite is a unique MI environment where radiographers deliver prescription medi-
Attitudes; cines to patients via intravenous (IV) means through an injector system. This paper
Practices; describes the development of a survey that informs the use of IPC processes in the CT suite.
Radiographers Methods: Standard Precautions via current national guidelines formed the benchmark of the
survey, with a KAP survey used as the framework to explore IPC. The questions and associated
responses are developed based on the National Health and Medical Research Council (NHMRC)
guidelines, industry/professional protocols and adapted to the equipment and practices
commonly used in the CT suite of MI departments by radiographers and nurses.
Results: Key survey development steps are described to include the justification of the bench-
marking source, the survey framework and design. Detailed information is given to show the
evolution of truth statements and sources, KAP question variations, and rationales for the
methodology of question responses. National guidelines are mapped to survey questions and
responses and pilot testing reflections are included.
Conclusion: This paper reports on the construction of a standardised KAP survey for IPC spe-
cific to the CT suite in the Australian healthcare setting. The survey is ready for dissemination
amongst MI departments. Documented use will aid validation and reliability as a survey tool to
measure and map IPC specifically in relation to IV contrast administration.
ª 2023 The Author(s). Published by Elsevier B.V. on behalf of Australasian College for Infection
Prevention and Control. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).

* Corresponding author.
E-mail address: [email protected] (S.J. Lewis).
Twitter: @SarahLewisUSYD.

https://doi.org/10.1016/j.idh.2023.08.003
2468-0451/ª 2023 The Author(s). Published by Elsevier B.V. on behalf of Australasian College for Infection Prevention and Control. This is an
open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Please cite this article as: S. Hill, Y.A. Jimenez, D. Abu Awwad et al., Infection prevention and control in computed tomography: creating
a national survey, Infection, Disease & Health, https://doi.org/10.1016/j.idh.2023.08.003
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S. Hill, Y.A. Jimenez, D. Abu Awwad et al.

Highlights

 There are no national approaches to understanding infection prevention and control atti-
tudes and practices of Australian radiographers, and limited guidance about knowledge
standards.
 The CT suite presents IPC risks through delivering medicines by radiographers and other
staff.
 The development of an IPC survey with a KAP approach is described and mapped to national
guidelines on standard precautions.

Introduction acquisition in MI IPC studies although no validated survey

was found. This was confirmed in a further review, where
Infection prevention and control (IPC) is a key factor in IPC surveys in MI were found to be tailored to small locales,
providing high-quality healthcare services in all clinical with survey items aimed at specific MI staff, interventions
settings. The practice of IPC requires Health Care Workers and settings or modalities within a particular setting (such
(HCW) to understand, have a positive attitude towards, and as a single hospital) and national guidelines were infre-
an integrated approach to IPC within their practice to quently referenced or absent [12].
ensure the safety of themselves, their colleagues, the pa- There are a variety of MI departments and radiological
tient, and the broader community [1e3]. The Australian procedures found in the Australian healthcare setting,
Commission on Safety and Quality Health Care (ACSQHC) requiring IPC practices specific to location, case mix and
identifies that IPC aims to reduce transmission risk related overall IPC safety. The Computed Tomography (CT) suite,
to infections between a range of people in the healthcare although not considered a sterile environment, hosts sterile
environment, including patients and HCW [4]. procedures such as venipuncture for contrast administra-
IPC requires constant review and action across all levels tion and invasive procedures such as drainages and thera-
of the health system, including government and policy peutic interventional injections and biopsies [13]. Within
makers, and employees and those who access healthcare the CT suite, radiographers also provide power-injected
services [5]. Two main subcategories, Standard Precautions prescription medicines to patients in the form of intrave-
(SP) and Transmission Based Precautions (TBP) are primary nous (IV) contrast. The risk of HAI may be increased due to
components of IPC [6,7]. According to the ACSQHC [8], SP the complexity of devices, tubing, multiple medicines given
are the frontline strategies for minimising healthcare together or at a similar time, and the use of multi-use,
associated infections (HAI) via transmission pathways. multi-patient doses of contrast and saline. The complex
These precautions are used when providing care to all pa- environment, case mix and workload in the CT suite, ne-
tients, irrespective of their infection status. TBP are used in cessitates IPC benchmarking, monitoring, and subsequent
conjunction with SP when specific contact, droplet and/or provision of focused, relevant, and up-to-date IPC practices
airborne precautions for patients are required [8]. and techniques to ensure quality, consistent healthcare
Knowledge, Attitudes and Practice (KAP) surveys are services.
valuable for understanding behaviour, particularly in This paper describes the development of a KAP survey of
health-related fields [9]. Surveys are an established method IPC by MI staff who work in the CT suite. The aim of the
for obtaining information as they are well understood by paper is to document how a large MI survey tool in IPC was
participants, can be disseminated to a target population developed in alignment with broad national guidelines and
electronically and often reach many participants without to assist health researchers who also wish to study this area
geographic restrictions [9]. Using KAP surveys can assist or undertake similar methodological inquiry. The final sur-
with aligning complex concepts, such as an ‘attitude’, to vey can be found in Appendix 1, with the intention that
measurable units, to specifically compare an individual’s other researchers will continue to create a deep under-
knowledge and practice, or a concept across a cohort [1]. standing of IPC in the CT suite and more broadly in MI.
These surveys provide data and perspectives for future
planning, education and interventions for improved prac-
tice as well as providing understanding of risk management Background
or scenarios [10].
The medical imaging (MI) department is a complex Two recent research outputs failed to identify a reference
healthcare environment where constant technological up- benchmark of IPC in medical imaging published studies,
dates and varied caseloads create the need for awareness both in Australia and internationally [11,12].
of IPC, with SP practiced across all facets of practice [10]. A KAP surveys provide a standardised questionnaire that is
recent scoping review identified inter-related domains of easy to produce, distribute and quantify responses, and
IPC within the MI setting, suggesting that human factors, have been previously used in MI to a limited extent, rarely
such as staff knowledge and behaviour, play a key role in as a comprehensive KAP assessment, but rather as a single
IPC compliance and culture [11]. Jimenez and Lewis [11] or dual measure of KAP [9,12]. KAP surveys are used to
identified that surveys were the primary source of data provide a baseline of data at a point in time, and will be

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useful to track trends over time or prior to any intervention survey foundation was undertaken in two stages: estab-
or education program [6].The KAP survey style was deemed lishing the benchmark of standards and identifying a survey
appropriate for this study design due to its versatility and style that facilitated exploration of IPC in the CT suite.
ability to be adapted to other MI specialties, demographics,
and scenarios. Surveys provide demographic data on an Survey foundation
individual level and are often aggregated at a cohort level.
MI departments in the Australian healthcare setting often
Given that MI departments vary significantly, importance
incorporate different roles, and the targeted participants
was placed to identify an overarching document offering a
for this survey design were those specifically working in the
baseline for all subsequent standards. The National Health
CT suite.
and Medical Research Council (NHMRC) published the
The inclusion of demographic data is important for KAP
Australian Guidelines for the Prevention of Infection in
surveys particularly if baseline data can then progress to
Healthcare in 2019, providing the nationally accepted
intervention [6]. Information pertaining to the participants’
approach for IPC in Australia [7], and hence became the
workplace, education and experience provides a framework
benchmarking resource for the survey. This approach is
for understanding the specific work system in which the
recommended in the professional literature on survey
relationship between the HCW (such as a radiographer),
design [8], using existing literature, instruments and expert
technology and tools, organisation, tasks, and environment
reference documents.
occurs [14]. Understanding of the work system supports
identification of deficiencies in the delivery of high-quality
care to patients [14,15] providing opportunities for a tar- Study design
geted interventional approach to HAI risk minimisation. The
CT suite is not immune to HAI, with transmissions previously Demographics
described in relation to the use of contrast enhanced CT For this survey, the intention was to capture IPC in CT as
procedures [12,16e18]. Additionally, many radiographers self-reported by qualified registered diagnostic radiogra-
choose to specialise in CT, and hence the link between phers. However, we acknowledge that other staff, such as
experience, training and CT caseload as collected by de- nuclear medicine technologists, radiology nurses, radiation
mographic questions supports opportunity for statistical therapists, doctors, assistants, and wards people do work in
analysis. CT and may also be able to complete the survey with
Understanding specific CT suite ‘demographics’ offer modifications. Although students were not the target for
potential identification of CT specific areas of concern, this survey construction, the questions could be applied,
clarify areas for possible intervention and supports mapping with suitable modifications, to enrolled MRP students too.
an area that has not previously been reported in literature, Common social demographics were included in this survey,
such as procedural and human error in IPC related to IV such as working experience (years, position title), place of
contrast delivery in MI departments [5,6,11,12,14]. work, caseload, and qualifications.
Reviewing literature on IPC and compliance [16,17] The CT suite demographic questions in our survey design
identified themes that contribute to non-compliance, extended to capture information about how IV contrast and
which was considered an important element of IPC sur- power injector equipment is used in the clinical setting.
veys in MI. The following themes of ‘risk desensitisation’,
‘workplace culture’, ‘workload’ and ‘physical safety’ were Question development
identified as reasons for non-compliance to IPC. Exploring For question development, the ERG sought to provide def-
these variations of compliance is necessary to understand initions of knowledge and benchmarking practices, fol-
potential areas for breach of SP and increased HAI risk. lowed by identification of the scope of the KAP questions
for inclusion. Finding the definitions for concepts requiring
benchmarking required breaking down CT practices into
Methods component parts (Table 1). This process was performed in
collaboration with the ERG, and the definitions from
An expert reference group (ERG) was established to sourced documents for this questionnaire were founded on
develop the survey. This included a total of four Australian definitions of IV contrast provided by product information
registered Medical Radiation Practitioners (MRP) with from Bayer Australia [14] and patient use definitions were
research qualifications: 2 (XX, XX) of the researchers have defined by the NHMRC guidelines [7]. The Medical Radiation
current and extensive CT imaging experience as Diagnostic Practice Board of Australia’s (MRPBA) Professional Capa-
Radiographers. A further two members of the ERG are bilities were also searched for conceptual best practice.
experienced MRP researchers in survey design in MI with However, the professional capabilities expression related
registration in Diagnostic Radiography (XX) and Radiation to IPC is very broad in “protect and enhance patient/client
Therapy (XX). A further three industry experts with expe- safety” with the enabling components stated as an expec-
rience in IPC and microbiome in clinical applications tation to “identify and manage risk of infection, including
related to radiology medical devices and healthcare regu- during aseptic procedures” [Domain 5.2] [15]. Domain 5.2
lation were members of the ERG (see acknowledgments). professional capabilities do not specifically mention
Survey development followed a sequential process of contrast administration or medical devices, but rather
survey foundation and study design. Study design included contrast media is defined and expressed as a ‘medicine’
identification of target demographics, question develop- under Domain 2.8 (and the Key Terms Table) and radiog-
ment, and question response development (Fig. 1). The raphers are required to have the capability to “apply

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Infec on,
•Literature
Preven on and
review
Control

Survey •Benchmarking Standards

Founda on •Survey Style

Study Design: •Target Par cipants

Demographics •Target Demographics

•Benchmarking Defini ons (Table 1)

Study Design: •Iden fying KAP
Ques on •Mapping KAP Ques ons with Benchmarks (Table 2)
Development •Sourcing Other Ques ons

•Knowledge Sources
Ques on •KAP Ques on Development
Response
•Compliance Responses
Development
•Open Response Ques on
(Results: Table 3)
•Pilot Tes ng

Ques on Use •Survey Valida on

and Valida on •Scope and
(Discussion) Extension

Fig. 1 Methodological stages of survey development. KAP: Knowledge, Attitudes and Practice (KAP).

knowledge of safe and effective use of medicines” [15]. ‘Risk desensitisation’ and ‘workplace culture’ were created
Questions or concepts that were not relevant to the CT to explore known variations of compliance that had been
suite from the NHMRC guidelines were not included or identified by other similar health professions [16,17]. Two
removed from the survey after ERG consensus. further concepts, ‘workload’ and ‘physical safety’, were
indirectly explored through the open-ended question to
Identifying KAP questions capture unknown or unexplored themes.
Combining the framework of the KAP style survey with the
benchmark of the national guidelines required multiple
Results
steps including the contextualisation of language to suit a
CT environment, such as reference to the IV contrast power
injector. Each important concept or truth statement was With the creation of the initial question bank, the ERG
altered to separately question participants knowledge of, reviewed the question bank and fine-tuned the questions
attitudes towards, and practice of the same concept. through consensus and experience. The final survey
Hence, each statement could be matched across the KAP included 77 questions. The complete survey is found in
components and mapped to the NHMRC concepts explored Appendix 1. The result options of the survey questions
in this study (Table 2). This included changing key words to outlined in the methods section are outlined below. Table 3
change sentences from a knowledge statement to reflect an summarises the results of the survey foundation and study
attitude towards the statement, and then modifying the design.
statement to create an action statement to reflect
practice. Question response development

Sourcing compliance questions Knowledge sources and knowledge question responses

Through consensus with the ERG, questions around These answers were designed as multi-selection response
compliance were added in the questionnaire in a separate questions to explore the general patterns of acquiring
section to the KAP questions. Specific questions themed as knowledge regarding IPC in the Australian CT environment

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Table 1 Mapping ‘Truth’ statements related to contrast administration in CT with NHMRC guidelines [7].
Knowledge Statement Truth NHMRC guidelines supporting Survey Question Number
Statement statement [7]
All patients are sources of infections TRUE Standard precautions must be used 36, 47, 58, 70, 72
regardless of their diagnoses. regardless of known or suspected
pathogens being transmitted via the
contract, droplet, or airborne route.
(p28)
The use of gloves replaces the need FALSE It is recommended that routine hand 37, 48, 59, 69
for hand hygiene. hygiene is performed (before
touching pt., before a procedure,
after procedure or body substance
exp, after touching pt., after
touching pts surroundings. (p30)
Hand hygiene is indicated after TRUE Hand hygiene must also be performed 38, 49, 59, 60, 71
removal of gloves. before putting on gloves and after the
removal of gloves. (p30)
CT tubing causes no risk to healthcare FALSE Healthcare workers may be exposed 39, 50, 61
workers. to infectious agents from infected or
colonised patients, instruments and
equipment, or the environment .
Avoid disconnection of administration
sets if possible to minimise the
potential of contamination of IV lines.
(p17,51)
All Intravenous (IV) Contrast Injection TRUE While shared clinical equipment 40, 51, 61
Equipment can be a source of comes into contact with intact skin
infection. only and is therefore unlikely to
introduce infection, it can act as a
vehicle by which infectious agents are
transferred between patients .
examples include x-ray machines
(equipment). Shared equipment
should be cleaned with a detergent
solution after each use with cleaning
agents compatible with the piece of
equipment being cleaned, as per
manufacturer instructions. (p63)
Disconnection and reconnection of IV FALSE Consider syringes or needles/canulae 41, 52, 62, 65, 71
contrast administration sets does as contaminated once they have been
not increase the risk of infection. used to enter or connect to a
patient’s IV infusion bag or
administration set . Avoid
disconnection of administration sets,
if possible, to minimise the potential
of contamination lines. (p51)
Transmission of infectious agents can TRUE Transmission of infectious agents 42, 53, 72
occur through hands that are in from the environment to patients
contact with CT department may occur through direct contract
equipment. with contaminated equipment, or
indirectly, for example, in the acute-
care setting, via hands that are in
contact with contaminated
equipment or the environment and
then touch a patient. (p55)
The IV contrast injector is considered TRUE Cleaning clinical surfaces including 43, 44, 54, 55, 66, 67
a frequently touched surface for equipment should always occur
infection transmissions. between patients or uses, regardless
of whether a surface barrier has been
used or not. (p65)
(continued on next page)

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Table 1 (continued )
Knowledge Statement Truth NHMRC guidelines supporting Survey Question Number
Statement statement [7]
The IV contrast injector is considered TRUE Cleaning clinical surfaces including 43, 44, 54, 55, 66, 67
a high-risk surface for infection equipment should always occur
transmissions. between patients or uses, regardless
of whether a surface barrier has been
used or not. (p65)
Hands must be washed with soap and TRUE Hands must be washed with soap and 45, 56, 64, 68
water after coughing, sneezing, water after coughing, sneezing, using
and/or using tissues. tissues, or after contract with
respiratory secretions or objects
contaminated by these secretions.
(p90)
Any fluids, including leaked IV TRUE Consider syringes or needles/canulae 46, 57, 61, 62, 65, 71
contrast are a source of infection as contaminated once they have been
after the IV contrast has been used to enter or connect to a
connected and/or disconnected to patient’s IV infusion bag or
the patient. administration set . Avoid
disconnection of administration sets,
if possible, to minimise the potential
of contamination lines. (p51)
Note: NHMRC Z National Health and Medical Research Council. IV Z Intravenous. CT Z Computed Tomography.

[16]. The multi-selection responses allow respondents to practice of the statements. For example, the statement “I
select any possible sources as a checklist, with an option to use gloves to replace the need for hand hygiene” had the
select ‘other’, which prompted an open response. Given response options of ‘always’, ‘frequently’, ‘occasionally’,
the varied workplace environments and differing ‘rarely’, or ‘never’. There were questions specifically
requirements between the public hospital and private relating to the CT IV contrast power injector, where
clinic, it was important to understand how participants response options were ‘between every patient’, ‘periodi-
acquired knowledge about IPC and contrast administration, cally during the day’, ‘once a day’, ‘a few times a week’,
and if there was a noticeable difference in knowledge ‘once a week’, or ‘infrequently’.
sources between any demographic subgroups. See Appendix
1 for multi-selection options, which included work col- Compliance responses
leagues, policies, product guidelines, manufacturer guide- The survey was constructed to assist in exploring scenarios
lines, etc. where participants believed they would modify their
The knowledge questions were formed as closed ques- compliance of IPC practices. These areas were related to
tions from the Australian guidelines [7] and presented as workplace culture and risk desensitisation as previously
‘truth’ statements where the answer responses were described by Morris and Jakobsen [17]. Both areas used 5-
selected to be either ‘True’ or ‘False’. When the partici- point Likert scales from ‘strongly agree’ to ‘strongly
pant indicated a statement was true or false, they were disagree’. The workplace culture statements used MI
then assigned a correct or incorrect response to the ‘truth’ appropriate terminology such as “my department” to
of that statement. The statements were posed in such a portray the CT suite environment in which participants are
way that not all correct responses were all true or all false. working.

Attitudes responses Open response question

Attitude responses were formed on a 5-point Likert scale. The question “If I was to not adhere to standard and
These were scaled as ‘strongly agree’ to ‘strongly disagree’ transmission-based precautions, it is most likely when .”
with a neutral response at the mid-point. The core of the was posed as the only completely open response question.
statement from knowledge questions is maintained, with It is also the only question that encompasses IPC in its en-
the wording changed such that the statements were per- tirety, including both SP and TBP [7]. This provides re-
taining to an individual’s attitude or the perception of an searchers with the opportunity to discover their own blind
attitude toward the statement. spots or biases regarding variations in attitudes and prac-
tice of IPC in the MI department. Given the complexity of
Practice responses clinical decision making [16], the open response provides
These answer options were also in the form of a 5-point participants with free text to discuss variations of what
Likert scale. The answer responses were modified to be they perceived to be accepted practice. This was the final
focused on the level of engagement or frequency of question in the survey (Table 3, Q77).

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Table 2 KAP question variations related to SP and contrast administration in the CT environment.
Knowledge Attitudes Practice
All patients are sources of infections I consider patients to be a source of I use standard precautions for all
regardless of their diagnoses infection regardless of their diagnosis patients as they are a source of
infection.
The use of gloves replaces the need I consider gloves an alternate to hand I use gloves to replace the need for
for hand hygiene hygiene hand hygiene
Hand hygiene is indicated after I consider hand hygiene to be I use hand hygiene after removing
removal of gloves warranted after removing gloves gloves
CT tubing causes no risk to healthcare My workplace doesn’t consider I practice standard precautions when
workers needleless connections of tubing as a dealing with needleless connections
source of infection of IV contrast tubing
All IV Contrast Injection Equipment I consider IV contrast injection I clean IV contrast equipment
can be a source of infection equipment a source of infection
Disconnection and reconnection of IV The disconnection and/or I disconnect and reconnect the IV
contrast administration sets does reconnection of IV contrast contrast administration set for a
not increase the risk of infection administration increases infection patient if required for the
risk examination
Transmission of infectious agents can I believe that the transmission of I practice standard precautions when
occur through hands that are in infectious agents can occur through dealing with CT department
contact with CT department hands that are in contract with CT equipment
equipment department equipment
The IV contrast injector is considered My workplace considers the IV At my workplace, the IV contrast
a frequently touched surface for contrast injector to be a frequently injector is cleaned
infection transmissions touched surface for the spread of
infection
The IV contrast injector is considered My workplace considers the IV At my workplace, the IV contrast
a high-risk surface for infection contrast injector to be a high-risk injector is cleaned
transmissions surface for the spread of infection
Hands must be washed with soap and I consider it good practice to wash my I always wash my hands with soap and
water after coughing, sneezing, hands with soap and water after water after coughing, sneezing, or
and/or using tissues. coughing, sneezing of using tissues. using tissues.
Any fluids, including leaked IV I consider any fluids to be sources of I use standard precautions when
contrast are a source of infection infection after the IV contrast has connecting and/or disconnecting the
after the IV contrast has been been connected and/or disconnected IV contrast lines from the patient
connected and/or disconnected to to the patient
the patient.
Note: Knowledge Z stem or core concept/truth statement. Attitude Z Belief/attitude focused word within the attitude statement.
Practice Z Verb used/focal point of practice within the statement. IV Z Intravenous. CT Z Computed Tomography.

Pilot testing with soap and water was more directly stated in the
tBurns et al., recommends interactive pilot testing of NHMRC guidelines [7]. A second discrepancy detected
questionnaires by colleagues or potential participants to through pilot testing was with the question ‘Needleless
ensure questions are not misinterpreted and subsequently connections of tubing cause no additional risk to health-
improve the questionnaire before use [26]. Two radiogra- care workers’. This question was initially constructed on
phers with >10 years and active employment in the CT the discussion in the NHMRC guidelines, which mention
suite piloted the survey, and their feedback and responses that there has been reduced percutaneous risk for staff
were compared to the associated NHMRC guidelines for with the use of needleless connections [7]. However, it
each truth statement. Where there were disagreements became clear during pilot testing that there is no standard
between the radiographers, the survey questions were baseline of ‘risk’ to compare the risk that needleless
updated to ensure the NHMRC concepts are being clearly connections pose. The question alone was considered un-
articulated in the questions and aligned with proper IPC in clear as to whether the risk is compared to needle con-
the clinical workplace. In this paper we give details of the nections or scenarios where SP apply. While needleless
two changes made because of pilot testing. Firstly, alcohol connectors have been associated with reduced needlestick
hand rub was initially used for the statement ’Hands must injuries to healthcare workers [7], they have been found to
be washed with soap and water after coughing, sneezing, be a common contaminated area in contrast injectors [27].
and/or using tissues’. After pilot testing by radiographers, Hence the question was changed to ‘CT tubing causes no
the question was changed because though alcohol hand rub risk to healthcare workers’ as suggested by the pilot
can be used and encouraged in clinical settings, washing radiographers.

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Table 3 Question sections and the corresponding themes.

Section Question Theme Literature
Number Supporting Question
Demographics 1e10 Personal and Professional demographics [18,19]
Demographics 11e14 Workplace Demographics [18,19]
Demographics 15e22 Use of IV contrast and IV contrast power injector [14,20,21]
Knowledge Sources 23e25 Workplace IPC teams, policies and procedures, specific IPC [18,19,22]
received
Knowledge Sources 26e30 Sourcing information and sourcing information if perceived [22,23]
problem arouse
KAP 36e67 Standard Precautions [6,7,9,19,22e25]
Workplace Culture 68e72 Workplace culture surrounding illness, provision of PPE, value [18,19,22]
of IPC, wasting resources, autonomy of decision making
Risk Desensitisation 73e77 Busyness, aseptic technique, reliance on built in safety [18,19]
features, outpatients vs inpatients
Note: IV Z intravenous, IPC Z Infection Prevention and Control, PPE Z Personal Protective Equipment, KAP Z Knowledge, Attitudes
and Practices.

Discussion reliability is also to be determined, although the intention

is that such a national tool as described in this paper would
To date, there is no validated survey for IPC and IV contrast allow for interventions to be undertaken [24]. The purpose
administration in the CT suite [11,12]. High standards of of this paper is to document the procedural steps of
knowledge, attitude towards, and practice of IPC are developing a KAP survey for IPC and contrast administration
necessary to reduce the risk of transmission of HAIs within in CT, which has not previously been reported in interna-
the MI department via the administration of IV contrast, tional literature.
with previous studies of nurses demonstrating that high Given that the intended demographics for the question-
scores in knowledge and attitude may not translate to naire was to include both the acute (public hospital) and
sound IPC where the actual practice of IPC technique is non-acute (private practice) CT suite environments, the
lacking [3]. Development of a survey to provide bench- authors acknowledge that the NHMRC guidelines [7] provide
marking is imperative prior to intervention programs to a nationally accepted approach to IPC, which includes both
ensure appropriate, timely, and effective outcomes that SP and TBP. Whilst SP are to be adhered to in all settings,
improve patient safety and minimise HAI risk, and KAP TBP can be problematic in the private practice settings
surveys have been used to effectively measure the outcome because reliance is placed on the infectious status of the
of interventions addressing IPC although not in the field of patient to be known and autonomously disclosed [34]. Given
medical imaging [6,9,19]. the complexity of TBP in all clinical contexts, the scope of
This survey has undergone initial validation through the survey is limited to that of SP, except for the final open-
consultation with the ERG that assessed content in the ended question. SP is also important for benchmarking,
context of the validation criteria as described by Tsang et al. because it provides the basic principles of IPC in the
[28], and via pilot testing with separate radiographers. This Australian healthcare setting, although using the method-
included being validated for ‘content’ (most relevant and ology described in this paper, adaptation of the questions
important aspects of a concept), ‘face’ (meaning the survey may be required if variations of practice differ greatly. The
would be understandable and relevant to radiographers and survey does not specifically reference COVID-19 infection
radiology nurses), and ‘concurrent validation’ (the associa- practices and as such does not have dedicated PPE questions
tion of the questions to relate to an acceptable standard, related to IPC with infectious COVID-19 patients as this
such as a national guideline) [26]. For example, KAP surveys would be covered by TBP. However, recognising the severity
are a known, often validated and widely used survey style of the pandemic, and the emerging information in the early
internationally [1e3,6,9,18,22,23,25,29e33] and this months about its spread, several national and international
described development of a survey is based on current societies have provided best practice guidelines around IPC
Australian guidelines and draws upon current clinical for imaging rooms, including CT, and these could be addi-
knowledge of CT practices and contrast delivery, and tional features of any IPC survey [35].
research expertise [7,24]. After piloting, the stems of Furthermore, the survey’s target population are radi-
questions were modified to use language frequently used in ographers in the CT suite, with adaptation of the survey to
the Australian context and with options about IPC and power capture other demographic groups possible such as radi-
injectors that reflect commercial options found in the ology nurses who may share an occupational responsibility
Australian market. in delivering IV contrast. Using the framework described
The other remaining tests of survey validity, such as above, KAP questions can be contextualised to target
construct or criterion, are generally available after there is groups such as hybrid imaging suites, MRP students or even
strong engagement with any survey. The test-retest extending to acute care or community MI practices. Finally,

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Infection, Disease & Health xxx (xxxx) xxx

KAP surveys are primarily useful for development prior to Ethics

intervention or education programs [6,9] hence this survey
may be used as a pre- and post-intervention or education Ethics approval not required as this is a discussion paper,
program benchmark, and to determine short and long term although this survey has been approved by the Human
impacts of IPC education programs. At present, this survey Research Ethics Committee of the University of XXXX [2022/
has approval from the University of XXXX Human Research 493].
Ethics Committee (HREC) for use in Australia, indicating
that the survey has scientific rigor [2022/493].
Authorship statement
Other considerations
The conception and design of the study: SL, DAA, YJ, SH.
Acquisition of data; or analysis and interpretation of
Other features of survey design and developments to be
data: SH, DAA, YJ, SL.
considered, but are not described here, include ethical
Drafting the article or revising it critically for important
approval, the dissemination processes and research data
intellectual content: SH, DAA, YJ, SL.
security (RDS). Surveys generally require approval from a
Final approval of the version to be submitted: SH, DAA,
HREC, and a research data storage plan is necessary. As
YJ, SL.
each HREC will have unique needs, this process is not
described here as it will likely be localised to the HREC that
evaluates the survey design and scientific merit of each Conflict of interest
study. The purpose of this paper is to describe the meth-
odology that underpins the survey, which was designed to None (SH, DAA, YJ, SL)
be a national tool to measure KAP, with the results being
the survey formation, including detailed mapping of survey
questions, truth sources and survey response types. As Funding
such, this paper focuses on methodological procedures of
survey development, and outcomes of statistical analysis The work is supported by Imaxeon Pty Ltd research contract
are not presented. The creation of the survey is presented funding (2022e23; RC XXXX).
in the results section, with the KAP survey for CT IPC being
the main output as this is the first time that such a national
Provenance and peer review
survey has been created in the MI domain.
The challenges of investigating IPC through self-reported
surveys should also be considered, where a confounding Not commissioned; externally peer reviewed.
factor may be participants’ willingness to provide socially
desirable responses [11] or general bias in survey findings, Acknowledgements
when radiographers with more interest in IPC are more
likely to complete the survey, and whose opinions may
The authors would like to acknowledge the Expert Refer-
differ greatly from radiographers who choose not to engage
ence Group (MB, VM, AR) who provided valuable insights to
with the survey.
the development of the questionnaire related to IPC, the
use of medical devices and contrast media, and Dr XXX XXX
Conclusion from Sydney Pharmacy School, the University of XXXX for
advice related to prescription medicines.
In this paper, we provided the framework for the devel-
opment of a KAP survey for the CT environment in the Appendix A. Supplementary data
Australian healthcare setting related to IPC and, specif-
ically, contrast administration. Our research team is Supplementary data to this article can be found online at
working on deploying the survey nationally and reporting https://doi.org/10.1016/j.idh.2023.08.003.
the findings and the inclusion of the final survey is provided
to assist the use of the survey by other research groups, and
collectively, establish a baseline of IPC information related References
to the KAP of key occupational groups in MI. Extended use
of the survey will strengthen the understanding of its use- [1] Fink A. How to ask survey questions. 2003.
fulness for reliability and validity. The potential implica- [2] Gesser-Edelsburg A, Cohen R, Halavi AM, Zemach M. Moti-
tions for survey findings are in mapping and then improving vating healthcare professionals (nurses, nurse assistants,
the understanding IPC, and knowing the source of IPC to physicians) to integrate new practices for preventing
Australian radiographers so that this information can be healthcare-associated infections into the care continuum:
turning Positive Deviance into positive norms. BMC Infect Dis
validated, contextualised, and better used in clinical
2021;21(1):495.
practice. Additionally, a better understanding of attitudes [3] Nasiri A, Balouchi A, Rezaie-Keikhaie K, Bouya S, Sheyback M,
and practices of Australian radiographer would allow for a Rawajfah OA. Knowledge, attitude, practice, and clinical
risk matrix to be developed to identify high to low-risk recommendation toward infection control and prevention
scenarios and work-based and personal strategies to reduce standards among nurses: a systematic review. Am J Infect
risk and prevent infection. Control 2019;47(7):827e33.

9
 + MODEL
S. Hill, Y.A. Jimenez, D. Abu Awwad et al.

[4] (ACSQHC), A.C.o.S.a.Q.C.. Infection prevention and con- com/college/document-library/ranzcr-iodinated-contrast-

trol. 2022. https://www.safetyandquality.gov.au/our-work/ guidelines.
infection-prevention-and-control. [22] Nalunkuma R, Nkalubo J, Abila DB. Knowledge on infection
[5] WHO. Global Report on infection Prevention and control. prevention and control and associated factors among under-
2022. 2022 [cited 2022; 148]. graduate health professional students at makerere university
[6] WHO. Advocacy, communication and social mobilization for college of health sciences, Uganda. PLoS One 2021;16(8):
TB control: a guide for developing knowledge, attitude and e0255984.
practice surveys. 2008. [23] Esposito MR, Guillari A, Angelillo IF. Knowledge, attitudes, and
[7] NHMRC. Australian guidelines for the prevention and control practice on the prevention of central line-associated blood-
of infection in healthcare. National Health and Medical stream infections among nurses in oncological care: a cross-
Research Council; 2019. sectional study in an area of southern Italy. PLoS One 2017;
[8] (ACSQHC), A.C.o.S.a.Q.C. Standard and Transmission based 12(6):e0180473.
precautions. 2022. https://www.safetyandquality.gov.au/ [24] NHMRC. Clinical educators guide. In: A.C.o.S.a.Q.i.H. Care,
our-work/infection-prevention-and-control/standard-and- editor. Australian guidelines for the prevention and control of
transmission-based-precaution-posters. infection in healthcare. National Health and Medical Research
[9] Andrade C, Menon V, Ameen S, Kumar Praharaj S. Designing Council; 2019.
and conducting knowledge, attitude, and practice surveys in [25] Tenna A, Stenehjem EA, Margoles L, Kacha E, Blumberg HM,
psychiatry: practical guidance. Indian J Psychol Med 2020; Kempker RR, et al. Infection control knowledge, attitudes, and
42(5):478e81. practices among healthcare workers in Addis Ababa, Ethiopia.
[10] Craciun H, Mankad K, Lynch J. Risk management in radiology Infect Control Hosp Epidemiol 2013;34(12):1289e96.
departments. World J Radiol 2015;7(6):134e8. [26] Burns KEA, Duffett M, Kho ME, Meade MO, Adhikari NKJ,
[11] Jimenez YA, Lewis SJ. Infection prevention and control in the Sinuff T, et al. A guide for the design and conduct of self-
medical imaging environment: a scoping review. Insights Im- administered surveys of clinicians. CMAJ (Can Med Assoc J) :
aging 2023;14(1):121. https://doi.org/10.1186/s13244-023- Canadian Medical Association journal Z journal de l’Associa-
01470-1. tion medicale canadienne 2008;179:245e52. https:
[12] Jimenez YA, Hill S, Lewis SJ. Infection prevention and control //doi.org/10.1503/cmaj.080372. 3.
in medical imaging surveys: The need to map to guidelines to [27] Goebel J, Steinmann J, Heintschel von Heinegg E,
address systemic issues? Infection. Disease & Health; 2023. Hestermann T, Nassenstein K. Bacterial contamination of
[13] Ilyas F, Burbridge B, Babyn P. Health care-associated in- automated MRI contrast injectors in clinical routine. GMS
fections and the radiology department. J Med Imag Radiat Sci Hygiene and Infection Control 2019;14. https://doi.org/10.
2019;50(4):596e606 e1. 3205/dgkh000321. Doc05eDoc05.
[14] Australia B. Australian product information: ultravist [28] Tsang S, Royse CF, Terkawi AS. Guidelines for developing,
(iopromide). 2022 [cited 2022; Available from: https:// translating, and validating a questionnaire in perioperative
radiology.bayer.com.au/products/ultravist. and pain medicine. Saudi J Anaesth 2017;11(Suppl 1):S80e9.
[15] Australia MRPB. Professional capabilities for medical radiation [29] Stein AD, Makarawo TP, Ahmad MFR. A survey of doctors’ and
practitioners. 2020. nurses’ knowledge, attitudes and compliance with infection
[16] Ray-Barruel G, Woods C, Larsen EN, Marsh N, Ullman AJ, control guidelines in Birmingham teaching hospitals. J Hosp
Rickard CM. Nurses’ decision-making about intravenous Infect 2003;54(1):68e73.
administration set replacement: a qualitative study. J Clin [30] Abdelrahman MA, Alhasan M, Alewaidat H, Rawashdeh MA, Al
Nurs 2019;28(21e22):3786e95. Mousa DS, Almhdawi KA. Knowledge of nosocomial infection
[17] Morris KY, Jakobsen R. Central venous catheter access and control practices among radiographers in Jordan. Radiography
procedure compliance: a qualitative interview study exploring 2017;23(4):298e304.
intensive care nurses’ experiences. Intensive Crit Care Nurs [31] AlJohani A, Karuppiah K, Mutairi Alya Al, Mutairi Abbas Al.
2022;69:103182. Narrative review of infection control knowledge and attitude
[18] Rabaan AA, Alhani HM, Bazzi AM, Al-Ahmed SH. Question- among healthcare workers. J Epidemiol Glob Health 2021;
naire-based analysis of infection prevention and control in 11(1):20e5.
healthcare facilities in Saudi Arabia in regards to Middle East [32] DeJoy DM, Searcy CA, Murphy LR, Gershon RRM. Behavioral-
Respiratory Syndrome. J Infect Public Health 2017;10(5): diagnostic analysis of compliance with universal precautions
548e63. among nurses. J Occup Health Psychol 2000;5(1):127e41.
[19] Russell D, Dowding DW, McDonald MV, Adams V, Rosati RJ, [33] Silva O, Palomino S, Robles A, Rı́os J, Mayta-Tovalino F.
Larson EL, et al. Factors for compliance with infection control Knowledge, attitudes, and practices on infection control
practices in home healthcare: findings from a survey of measures in stomatology students in Lima, Peru. J Environ
nurses’ knowledge and attitudes toward infection control. Am Public Health 2018;2018:8027130.
J Infect Control 2018;46(11):1211e7. [34] Welfare., A.I.o.H.a. Infectious and communicable diseases.
[20] Indrajit IK, Sivasankar R, D’Souza J, Pant R, Negi RS, Sahu S, 2022. https://www.aihw.gov.au/reports/australias-health/
et al. Pressure injectors for radiologists: a review and what is infectious-and-communicable-diseases.
new. Indian J Radiol Imag 2015;25(1):2e10. [35] International Society of Radiographers and Radiological
[21] Radiologists, T.R.A.a.N.Z.C.o. Iodintated contrast media technologists. ISRRT response document. 2020. NEW_ISRRT_
guideline. 2018 2022. Available from: https://www.ranzcr. COVID_19_Response_document_052020.pdf.

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