Knowledge, attitude, and practice toward the daily management of PICC in critically ill cancer patients discharged from intensive care units

Introduction

Peripherally inserted central catheters (PICCs) provide an effective venous channel for chemotherapy in patients with malignant tumors. PICC is superior to other indwelling needles in reducing the stimulation of drugs on blood vessels, drug extravasation, and the pain of repeated puncture. Moreover, PICCs have a longer indwelling time, which can significantly improve the patients’ quality of life.^1–3 Compared to a central venous catheter, a PICC is easy to use and safe to manipulate, resulting in less severe complications.^4–6 However, as a foreign body introduced into blood vessels, complications may occur because of improper operation, incorrect tip placement, mismanagement, or delayed maintenance.^7–9 It has been reported that complications are possible throughout the entire indwelling period, with an overall incidence rate of 30%–40%. The incidence rate in the first month of indwelling is high, but it decreases after the fifth week. Common complications include infections, phlebitis, tube blockage, effusion of blood or fluids, broken catheter, or exfoliation.

The higher incidence of complications among malignant tumor patients may be associated with the following factors. First, there was close association between hypercoagulability and thrombus, with the incidence of thrombus in tumor patients being 4–7 times higher than that in nontumor patients.¹⁰ Second, chemotherapeutic drugs not only weaken immunocompetence, which could lead to infection, but also cause thrombus.¹¹ Third, inadequate daily management of PICCs may correlate with patients’ physiologic and psychological states, the side effects of chemotherapy, and patients’ age, among others. Fourth, patients with indwelling PICCs are required to stay at home because of the long chemotherapy intermission. However, it appears that the incidence of complications is higher when care is provided at home rather than at a hospital.¹² Thus, the prevention of PICC-related complications is a priority and challenge for nursing.

KAP for PICC daily management refers to the knowledge, attitude, and practice of patients regarding the prevention and reduction of PICC-related complications. Catheter management in daily life includes the recognition of any problems, the handling of exceptions, patient confidence, and observation of the tube and membrane application and of the movements of the PICC in the indwelling arm, but it does not include catheter maintenance (i.e., dressing changes, tube blowing). Few studies have investigated the direct effect of KAP on PICC daily management among cancer patients. In this study, a survey on the current status and impact of KAP on PICC daily management was administered with the goal of implementing proper nursing measurements based on influential factors likely to improve patients’ daily management ability and to decrease the incidence of PICC-related complications.

Methods

Subjects

A survey questionnaire was conducted among malignant tumor patients selected by convenience sampling at two intensive care units (ICUs) in China from January to December 2016. The surveys were conducted within the 3 months of the patients’ discharge from ICUs. Written informed consent to participate in this survey was obtained from all patients, and the use of related clinical materials was approved by institutional ethics committees of Shanghai 9th People’s Hospital and Huashan Hospital North, and this study was performed in accordance with the Helsinki Declaration on ethical principles for medical research involving human subjects. Patients who met the inclusion criteria were 1) volunteered to participate in this study and provided a signed informed consent form; 2) had clear consciousness and self-care ability without communication barriers; 3) had been diagnosed with malignant tumors; 4) underwent the PICC tube procedure; 5) had the literacy and ability to work with the investigators. The following were the exclusion criteria for patients with malignant tumors: 1) patients who had cognitive disorder or other major illness; 2) patients who were unwilling to participating in this study.

Questionnaire development

The questionnaire was developed on the basis of numerous literature reviews conducted by the investigators and was revised by five experts in oncologic nursing; it was also tested and showed a 95% validity (Supplementary materials). Face validity considering the layout and structure of the KAP-related questionnaire was determined by the oncologists, research personnel, and statistician developing the questionnaire toward the daily management of PICC among patients with malignant tumor. Response rates for all test questions were evaluated to determine the poorly designed questions, which were eliminated from the final questionnaire and provide a measure of linguistic validity. The questionnaire included items related to patients’ general and sociodemographic characteristics (gender, age, and so on), and the KAP-related items assessed the three dimensions of KAP. There were 27 items in total: nine assessed knowledge, ranging from the benefits of fisting exercises to catheter exfoliation; seven assessed attitudes toward learning PICC management and PICC management itself; and 11 assessed practices regarding how to care for the PICC in daily life. Scores were counted using 5-point Likert scales. Each patient participant was asked to read a series of statements and rate the degree to which they agreed with each statement using a 5-point Likert scale ranging from 1 (did not know at all or disagree) to 5 (know very well or agree strongly). The total points for all of the three domains of knowledge (nine items), attitude (seven items), and practice (11 items) were calculated for analysis. The questionnaire has been determined to be both a reliable and a valid tool for assessing PICC management in cancer patients. The internal consistency for the current sample as a whole was excellent (Cronbach’s α=0.887), and it ranged from good to excellent for the knowledge (Cronbach’s α=0.807), attitude (Cronbach’s α=0.813), and practice (Cronbach’s α=0.809) subscales. The data of the surveys were collected by patient self-reports. The diagnosis of the disease was confirmed by patient clinical and pathologic findings.

Statistical analyses

Descriptive statistics were used to summarize patient characteristics as well as responses to items regarding patients’ KAP toward PICC management. We used the Kolmogorov–Smirnov test to assess normality of each dataset. Continuous data were expressed as mean±SD and compared using independent-samples t-test for differences between demographic variables and the scores on the 5-point Likert scale for KAP. Otherwise they were expressed as median (interquartile range) if not normally distributed and compared using Mann–Whitney U-tests. Multivariate stepwise linear regression analysis was used to determine the relationships between participants’ characteristics and the KAP score for PICC management. All statistical analyses were performed using SPSS version 21 (SPSS, Chicago, IL, USA), and statistical significance was defined as a P-value <0.05.

Results

Patient characteristics

Table 1 presents a summary of study patients’ characteristics. In total, 155 questionnaires were collected from two hospitals. After excluding three questionnaires with incomplete responses, 152 questionnaires remained in the analysis. The patients’ mean age was 49.3 years (range 20–79). The mean PICC indwelling time was 69.8 days (range 30–173).The total mean KAP score was 105.03±8.80 points, and the standard score was 77.80±6.52 points, among which the standard score for knowledge was the lowest (72.47±8.44 points) and the standard score for practice was the highest (80.56±7.23 points). Detailed clinical factors affecting patient scores on KAP toward the daily management of PICC are presented in Table 2.

Table 1 Respondent characteristics of included patients Abbreviations: ICU, intensive care unit; PICC, peripherally inserted central catheter.

Table 2 Clinical factors affecting patient scores on knowledge, attitude, and practice toward the daily management of PICC Note: Data are presented as means±SD. Abbreviation: PICC, peripherally inserted central catheter.

Knowledge toward the daily management of PICC

The average score for knowledge of the daily management of PICC was 32.61±3.80 points. The average standard score was 72.47±8.44 points. The standard score was divided into nine items, in which the question on emergency treatment knowledge had the lowest score (5.29±1.35 points), while questions on the knowledge of PICC maintenance had the highest score (9.05±0.97 points). The four knowledge items with the lowest scores are presented in Table S1.

Attitude toward the daily management of PICC

The PICC management attitudes questionnaires for patients with malignant tumors consisted of two parts: beliefs related to daily management had a lower score (11.30±0.74 points), and attitude toward emergency treatment had a higher score (16.82±0.56 points). There were seven items related to attitude toward the daily management of PICC. Overall, 40.79% of patients had a standard score >80, and 72.06% of patients had confidence in PICC management. Among them, the question referring to “the need for immediate treatment in case of abnormal PICC dressing” had the lowest score (3.60±0.71 points). The question that referred to patients’ attitude toward the treatment of bleeding and exudate had the highest score (89.08±11.00 points). The four attitude items with the least scores are presented in Table S2.

Practice toward the daily management of PICC

The questionnaires on practice related to the daily management of PICC were divided into four parts including daily observation behavior (three items), daily life management (four items), engagement in exercise after indwelling PICC (three items), and timely maintenance (one item). Among them, timely maintenance had the best compliance and the highest standard score (90.13±10.29 points). Engagement in exercise after indwelling PICC had the worst compliance, with the lowest standard score (60.69±6.25 points). Among 152 patients, the average score was 44.31±3.98 points and the standard score was 80.56±7.23 points, 46.05% (70/152) of which had a standard score >80 points. Observation around the puncture site had the worst compliance, with an average score of 3.12±0.83 points. The four practice items with the least scores are presented in Table S3.

Factors affecting patients’ KAP toward the daily management of PICC

Here, the cumulative KAP score (the sum of scores of KAP) is the dependent variable. We conducted a multiple stepwise linear regression analysis using a single statistically significant factor derived from the univariate analysis of influencing factors that included the following: medical payment mode, educational degree, place of residence, occupation, PICC indwelling time, and patient age. The results of the multiple linear regression analysis showed that patient age, place of residence, PICC indwelling time, and educational degree influenced the total KAP score (P<0.05). Among them, patient age was a negative factor in total KAP score, while place of residence, PICC indwelling time, and educational degree were positive factors for total KAP score (Table 3).

Table 3 Results of multiple stepwise linear regression analysis of factors influencing patient knowledge, attitude, and practice toward the daily management of PICC Abbreviation: PICC, peripherally inserted central catheter.

Discussion

This study demonstrated that KAP toward the daily management of PICC was at a medium level, which leaves room for improvement. The most influential factors in the PICC daily management total scores among cancer patients were patient age, place of residence, PICC indwelling time, and educational degree.

Current situation regarding patient knowledge toward the daily management of PICC

The standard scores for both the basic knowledge and the PICC indwelling precautions toward the daily management of PICC were >80 points each, while the standard scores for both emergency treatment knowledge and prevention knowledge were <70 points. This indicated that patients possessed a certain degree of PICC basic knowledge and precautions but lacked knowledge regarding emergency treatment and prevention; these findings were similar to those obtained by Li et al.¹³ These results are mostly due to the following reasons: the relatively low incidence of such emergency situations and the concomitant relative inattention paid to them by nurses and patients alike, the inadequate understanding of PICC-related complications, the lack of prevention knowledge, the nurses’ insufficient knowledge of changes in foreign guidelines, and the difficulty in understanding the professional nursing skills required for PICC.

Current situation regarding patient attitudes toward the daily management of PICC

The standard score for patient attitudes toward the daily management of PICC was 80.32±9.09 points, indicating that patients had a good attitude toward seeking medical treatment. However, when patients did not recognize the harmful factors, they lacked attitudes that favored the seeking of medical treatment. In our study, 40.79% of the patients had a standard score >80, while 49.70% of the patients would take the initiative to learn PICC-related knowledge, indicating that the attitude of cancer patients was above the middle level. Nevertheless, 72.06% of the cancer patients were confident in the daily management of PICC, which was consistent with the findings by Wei et al¹⁴ but lower than the level reported by Zhang et al.¹⁵

Current situation regarding patient practices toward the daily management of PICC

The standard score for patient practice toward the daily management of PICC was 80.56±7.23 points, ranging from 62.37±16.59 to 90.13±10.29 points among the items, indicating that the patients’ health behavior was not uniform, with a wide range of fluctuations in compliance, and that targeted health education is required. The standard scores for daily management and timely maintenance of PICC were both >80 points, while the standard scores for daily observation and engagement in exercise after indwelling PICC were both >70 points, indicating that the patients had good behavioral compliance with respect to daily management and timely maintenance but had poor compliance with daily observation and exercise after indwelling PICC. We found that only 32.89% of the patients observed the puncture site every day, and 49.34% of the patients would observe the PICC on their own, which was similar to previous findings.¹⁶

The factors influencing KAP toward the daily management of PICC among cancer patients

The results of the present study indicate that educational level is one factor influencing KAP score toward the daily management of PICC. Patients with a higher education level had higher total scores for KAP than those with a lower education level, which was similar to the results reported by Peng et al.¹⁷ Patients with a higher education level had a broader knowledge base relevant to the daily management of PICC and could easily understand the necessity for PICC management. This understanding led to the formation of positive and healthy beliefs that could ultimately facilitate the emergence of healthy behaviors. Conversely, the formation of healthy behaviors among patients with a lower education level was limited. The total KAP scores for patients living in rural areas were lower than those in nonrural areas, which was consistent with findings by Liu et al.¹⁸

This study showed that the longer the indwelling time was, the higher the total KAP score was. This might be due to patients’ gradual understanding of the benefits of PICC with prolonged periods of having an indwelling PICC. Consequently, they would generate positive beliefs and start taking the initiative to learn PICC-related knowledge.

The study showed that age was a limiting factor for KAP total score. The patients ranging from 20 to 39 years of age had the highest KAP total scores, while those from 60 to 79 years of age had the lowest total scores. This could be related to decreased organ functions related to perception, memory, and thinking¹⁹ and to the fact that elderly patients are not generally interested in participating in the treatment of disease.²⁰

This study is the first one to utilize the questionnaire of KAP score to assess the daily management of PICC in critically ill cancer patients discharged from ICUs. Up till now, we have found no similar reports regarding this topic. Despite the strengths, several limitations should also be addressed; for example, we used the convenient samples and patient self-reported surveys, which might have brought about bias to some extent.

Conclusion

The total KAP score was influenced by factors such as patient age, place of residence, PICC indwelling time, and educational degree, which should be improved. Improvements in KAP score are ultimately the responsibility of health education, a means of disseminating health knowledge through education and intervention to promote the formation of positive attitudes and beliefs, thereby changing adverse behaviors and establishing healthy ones. Therefore, in clinics, more attention should be paid to the role of knowledge and attitude on behavior change as well as its influential factors, thus reducing the complications of PICC and improving patients’ quality of life. We proposed that large prospective clinical study should be designed and more subgroup analyses could be conducted based on those investigated influencing factors of KAP status to better understand its effect.

Acknowledgment

This research was supported by the National Natural Science Foundation of China (grant no. 81701843).

Disclosure

The authors report no conflicts of interest in this work.

References

1.		Bortolussi R, Zotti P, Conte M, et al. Quality of life, pain perception, and distress correlated to ultrasound-guided peripherally inserted central venous catheters in palliative care patients in a home or hospice setting. J Pain Symptom Manage. 2015;50(1):118–223.
2.		Molloy D, Smith L, Aitchison T. Cytotoxic chemotherapy for incurable colorectal cancer: living with a PICC-line. J Clin Nurs. 2008;17(18):2398–2407.
3.		Parás-Bravo P, Paz-Zulueta M, Santibañez M, et al. Living with a peripherally inserted central catheter: the perspective of cancer outpatients-a qualitative study. Support Care Cancer. 2017;26(2):441–449.
4.		Kramer R, Rogers M, Conte M, Mann J, Saint S, Chopra V. Are antimicrobial peripherally inserted central catheters associated with reduction in central line-associated bloodstream infection? A systematic review and meta-analysis. Am J Infect Control. 2017;45(2):108–114.
5.		Pittiruti M, Brutti A, Celentano D, et al. Clinical experience with power-injectable PICCs in intensive care patients. Crit Care. 2012;16(1):R21.
6.		Yamaguchi R, Noritomi D, Degaspare N, et al. Peripherally inserted central catheters are associated with lower risk of bloodstream infection compared with central venous catheters in paediatric intensive care patients: a propensity-adjusted analysis. Intensive Care Med. 2017;43(8):1097–1104.
7.		Cotogni P, Pittiruti M. Focus on peripherally inserted central catheters in critically ill patients. World J Crit Care Med. 2014;3(4):80–94.
8.		Orme R, McSwiney M, Chamberlain-Webber R. Fatal cardiac tamponade as a result of a peripherally inserted central venous catheter: a case report and review of the literature. Br J Anaesth. 2007;99(3):384–388.
9.		Venkatesan T, Sen N, Korula P, et al. Blind placements of peripherally inserted antecubital central catheters: initial catheter tip position in relation to carina. Br J Anaesth. 2007;98(1):83–88.
10.		Khorana A, Fine R. Pancreatic cancer and thromboembolic disease. Lancet Oncol. 2004;5(11):655–663.
11.		Pongruangporn M, Ajenjo M, Russo A, et al. Patient- and device-specific risk factors for peripherally inserted central venous catheter-related bloodstream infections. Infect Control Hosp Epidemiol. 2013;34(2):184–189.
12.		Pei C. Experience in the centralized management of patients with PICC. J Nurs Adm. 2009;(4):51–52.
13.		Li S, Chen W, Chen Q, Yang Y. Effect of cognitive intervention on self-protection ability and health knowledge for cancer patients indwelling with PICC. Chin J Pract Nurs. 2012;10(35):3308–3309.
14.		Wei H, Zhao Q. The knowledge-attitude-practice on catheter maintenance in outpatients with peripherally inserted central catheter. Chin Nurs Manag. 2014;(5):472–475.
15.		Zhang X, Liao J. Influence of enhanced patient education on the patients’ knowledge and awareness of peripherally inserted central catheter. Chin J Clin Nutr. 2013;21(5):313–315.
16.		Zhang D, Wang S, Wang X, Han B. Investigation and research of self-care staus-quo in PICC patient. Nurse Practice and Research. 2011;8(2):101–103.
17.		Peng N, Jiang X. Influencing factors and countermeasures of the adherence of PICC discharged from hospital. Journal of Guiyang College of Traditional Chinese Medicine. 2014;36(4):140–142.
18.		Liu C, MQ Y, Lu Z, Zhao M. Investigation on self-management capability among cancer patients with PICC and its influencing factors. Chin J Nurs Educ. 2011;8(7):294–297.
19.		Zhang Q, Zeng H, Song L. Impact of cognitive training on cognitive function in aged community residents. Int J Nurs Sci. 2010;(2):16–18.
20.		Longtin Y, Sax H, Leape L, Sheridan S, Donaldson L, Pittet D. Patient participation: current knowledge and applicability to patient safety. Mayo Clin Proc. 2010;85(1):53–62.

Supplementary materials

Figure S1 Questionnaire for the assessment of knowledge, attitude, and practice toward the daily management of PICC among patients with malignant tumor. Abbreviation: PICC, peripherally inserted central catheter.

Table S1 The four knowledge items with the lowest scores Abbreviations: Max, maximal value; Min, minimal value.

Table S2 The four attitude items with the lowest scores Abbreviations: Max, maximal value; Min, minimal value.

Table S3 The four practice items with the lowest scores Abbreviations: Max, maximal value; Min, minimal value.