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Year : 2015  |  Volume : 4  |  Issue : 3  |  Page : 167-170

Survey of critical care nurses knowledge in pulmonary artery catheterization: A pilot study

Department of Internal Medicine, King Fahad Teaching Hospital of the University, AL-Khobar 31952, Saudi Arabia

Date of Web Publication9-Dec-2015

Correspondence Address:
Hatem O Qutub
King Fahad Teaching Hospital of the University, AL-Khobar 31952, P.O. Box. 40133
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2278-0521.171432

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Background: Pulmonary artery catheterization (PAC) has been used in a "Heart Specialist Medical Centre" in the Eastern Province in the Kingdom of Saudi Arabia, for Intensive Care Unit (ICU) patients more frequently compared to other similar establishments elsewhere. Critical care nurse's knowledge toward using PAC was, therefore, surveyed to rectify this matter and ultimately form guidance, update practice, and future usage policies. Methodology: This survey included 48 ICU–Critical care nurses. A questionnaire has been designed and validated, and that was distributed to collect information on participants' relevant backgrounds and the PAC use. The raw test scores were converted to percentages and median test scores also interquartile range were calculated. The median knowledge score was compared among different attributes using Mann–Whitney U-test. The value P < 0. 05 was accepted as significant. Results: The questionnaire has been sent to 48 participants, and all participants answered the questionnaire. The median knowledge score of handling PAC is significantly related to earlier received training, their ICU experience, and their confidence of handling PAC. Conclusions: This survey highlighted the interesting statistical facts about the extent of lack of knowledge and skills among participants. More importantly, the survey also determined the important shortfalls in practice of some experienced medical practitioners. More research is needed to identify why such shortfalls exist and how they have developed. The survey finally highlights the importance of having policies and protocols for all PAC-related procedures, and the regularly associated training to guarantee patients' welfare and well-being is met.

Keywords: Critical care, knowledge, nursing, pulmonary artery catheter

How to cite this article:
Qutub HO. Survey of critical care nurses knowledge in pulmonary artery catheterization: A pilot study. Saudi J Health Sci 2015;4:167-70

How to cite this URL:
Qutub HO. Survey of critical care nurses knowledge in pulmonary artery catheterization: A pilot study. Saudi J Health Sci [serial online] 2015 [cited 2020 May 29];4:167-70. Available from: http://www.saudijhealthsci.org/text.asp?2015/4/3/167/171432

  Introduction Top

While pulmonary artery catheterization (PAC) has been in use since the mid-1940s, it was only in 1971 that Swan et al. improved the catheter and made it suitable for the assessment of cardiac pump function. Since then, PACs have been widely used in critically ill patients for diagnosis and therapeutic guidance.[1] PAC kept being developed further to provide precise hemodynamic measurements of stroke volume, cardiac output, intracardiac and pulmonary artery pressures, estimation of systematic and pulmonary vascular resistance, and mixed venous oxygenation data from its blood sampling ability.[2] One of the setbacks in the widespread use of PAC is the cost. PAC is an expensive technique. One estimate of the use of PAC monitoring in the USA showed that, as of the year 2000, more than 1.2 million PACs were utilized annually, with the associated costs of over 2 billion US dollars. Another setback is the lack of expertise in its usage.[3] Its use and interpretations of its readings need skill and practice.[4] PAC practice guidelines have been published such as the ASA in the USA.[5]

A summary of best-practice guidelines in the usage of PAC is given in the Appendix (For Appendix please visit http://www.precisdanesthesiecardiaque.ch/Pdf/AnnEAnesth/Swan-Ganz.pdf). The last setback in the usage of PAC is the skepticism about its benefits. Many studies were made to assess its use.[6] According to one position, "PAC is traditionally used in the management of high-risk patients during and after cardiac and major noncardiac surgery."[7] The PAC is also helpful in determining the etiology of various possible conditions. It can be used in the management of patients with conditions where hemodynamic stability is important for improving an outcome or guiding therapy decisions (e.g., renal failure, sepsis, and burns).[8] It is also useful in determining fluid and vasoactive therapy during the acute phase of a patient's care.[9] On the other hand, there is growing evidence that the use of PAC does not necessarily lead to improved outcome.[10]

In the center, where the survey is conducted, patients' records show that the total number of patients admitted from January 2005 to June 2013 was 1660 patients. All patients suffered from various major diseases. The vast majority of these patients, 97.3% (n = 1615) were fitted with PACs. All PACs were inserted before the patients were admitted to Intensive Care Unit (ICU). Of these patients fitted with PACs, only 4.89% (n = 79) died. No study has been done to find out if the causes of these deaths were associated with the wrong usage of PACs. The aim of this survey to assess the knowledge of critical care nurses about PAC. Such a survey would make a contribution to good practice.

  Subjects and Methods Top

A 20-item questionnaire has been developed to measure the knowledge. The survey design is a cross-sectional, questionnaire survey. The questionnaires were sent to all critical care nurses who were handling PAC. The questionnaire purposively designed to measure the knowledge of nurses on different aspects of PAC utilization. In this survey, the participation was voluntary, and no time limit was set. The face and content validity have been confirmed by three experts in this field. Quarantine collaboration with colleagues and references to textbooks could not be monitored. This might have increased their score and introduced bias toward a higher score. This would theoretically give a more realistic reflection of knowledge at provider level in an average health care unit in Saudi Arabia.

Statistical analysis

Data were summarized as median and percentages appropriately. Each correct answer gets one score, and the total knowledge score was calculated, and also the median and percentage of correct answers were obtained. The knowledge score on PAC uses was compared between participants' sociodemographic and professional characteristics. Statistical inferences were made based on Mann–Whitney U-test. Two-sided P < 0.05 was considered statistically significant. The Statistical Package for Social Sciences IBM SPSS Statistics (version 19.0)[11] software was used for all data analysis.

  Results Top

A total of 48 ICU health care practitioners participated in the survey; the response rate was 100%. More than 70% (n = 35) were young with age range between 20 and 30 years; 95.8% (n = 46) were female; 90.0% (n = 43) were with experience between 1 and 9 years; and 95.8% (n = 46) were non-Saudis.

The average, overall knowledge score was 9.98 (61.8% ±12.8%) with a range of 5–12, out of a possible total of 13. [Table 1] and [Figure 1] clearly depict the lack of knowledge of the health practitioners who are handling PAC, especially in certain areas. In particular, it is alarming that most of the practitioners failed to answer correctly to questions related to need to record PAC waveform reading and mortality. In response to item, "PAC: Increases the mortality post-CABG" (question 16), only 14.5% (n = 7) answered correctly. Similarly, in response to, "In your opinion how often do we need to record PAC waveform reading" (question 8), only 27.1% (n = 13) answered correctly.
Table 1: Percentages of correct answers to each questions

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Figure 1: Overall percentages of correct answers for all questions

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[Table 2] provides the summary of total questionnaire score by participants' ICU experience in years. The median knowledge score of nurses who have more than 10 years of ICU experience was higher than that of participants who have experience <10 years. Median (interquartile range [IQR]): 11 (11–9) versus 10 (12–11).
Table 2: Comparison of ICU experience of the participants and the total questionnaire score

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From [Table 3], the median knowledge score of the participants who are confident was higher than that of among the participants who are not confident in PAC handling Median (IQR): 11 (11–9) versus 09 (10–9).
Table 3: Comparison of confidence level of the participants and the total questionnaire score

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[Table 4] clearly explains the association between the knowledge score of the nurses and the training status. The median knowledge score of the nurses who have received training on PAC was higher than that of participants who have not received any training. Median (IQR): 11 (11–10) versus 09 (9–8). This association is statistically significant with a P value 0.01.
Table 4: Comparison of training status of the participants and the total questionnaire score

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  Discussion Top

Different studies suggest that health care providers are unable to correctly interpret the data obtained from the PAC even if one assumes that these measurements are accurate. One study by Iberti et al., in which a 31-item examination on the PAC was completed by 496 North American "intensivists" found that only 67% of the answers were correct.[12] Similar results came from the European study by Gnaegi et al. in 1997.[13] The review results done by Ahrens also clearly proved the knowledge deficit among critical care nurses.[14]

The results of the current study also indicate that there are reasons to be concerned about the effective use of PAC. The results clearly show that a high percentage of participants have not got the necessary knowledge and skills to make an informed decision whether to use PAC or not or to make a decision on how to use PAC properly.

Associating sociodemographic and professional characteristics with knowledge level were not significant, but it is alarming that only 14.5% of the participants could answer correctly to the question "Do you think PAC increase the mortality post-CABG." There were not enough statistics that can determine the statistical significance between the factors and deaths due to PACs use in the Kingdom. Hence, more data and analysis are required to investigate this further, and that will be one of the major objectives of the extension of this project.

From [Table 2], there was a significant association between the level of experience and the knowledge score (P < 0.02). This is similar to the findings of the Australasian survey done by Johnston et al. where they have also found a significant association (P < 0.001).[15] The same association was also found to be a significant (P < 0.01) in the North American study.[12]

Incorrect interpretation and application of PAC-derived variables can cause even fatality. Any monitoring technique can only be as good as the interpretation of the data derived, and this requires adequate and ongoing training.[14] The results clearly show that the training status is significantly associated with the total score. The median scores are significant, and all participants should, therefore, be provided with extensive and regular training that empowers them to rectify and update their knowledge and skills. This survey was done for one specialist center in the province. However, the authors' experience leads them to believe investigating other centers, such as those with formal training on PAC.

From [Table 4], it is also clearly proven that the people who are confident in handling PAC received more knowledge score in the survey, or in simple sense people who have more knowledge is more confident to handle the PAC.

Devising a good practical guidance and protocol for PAC utilization are evidently needed, starting from the decision whether to use PAC or not in a patient with the recommendation of how and when to use it to the full (safely and cost-effectively) and remove it safely without compromising the patients' welfare and health.[16] This protocol should be comprehensive and should be regularly updated to encompass all factors continuously, emerging and deemed important while using PAC. Suitable, well-planned, and regular training schemes should be embedded in all yearly plans for all staff associated with PAC usage. This is to ensure that they are equipped with the right knowledge, skills, and competencies for PAC use.

Medical establishments should be aware of the importance of establishing and implementing quality assurance standards (QAS) (Ex: JCI) and clear guidance related to PACs proper use.[17] These QAS and guidance should be based on clear and valid guidance of recognized authorities in the field. The questionnaires results show consistent indications that medical practitioners need to improve their knowledge, skill, and competencies for safe and proper use and removal of PAC. Furthermore, it leads to the conclusion that participants should "brush the dust" of their skills regularly.

There are limitations to the present study. This pilot survey was conducted in a single cardiac center in the province and only included the critical care nurses from the particular hospital. Hence, the small sample size is a major limitation that reduces the power of the study. However, in our opinion, this small sample survey could enlighten few key issues that would lead us for the detailed study where we are planning to measure different attributes other than knowledge. A second limitation is the self-developed small questionnaire, which is able to measure only few aspects of knowledge. A more detailed questionnaire would have been useful to measure all aspects of different attributes such as skills and attitudes.

Finally, this survey is showing that medical establishments should not wait until the critical care providers misinterpret PAC data and harm the patients due to lack of knowledge, skills, and timely slippage of standards occurrence or whatever other reasons that might be discovered from future studies. Instead and until all reasons for bad practice are known and avoided, the establishment must provide a regular, effective, and valid training on PAC use, so that they preserve patients' safety from any potential and relevant harmful risk.


I wish to thank the following people for their help and support throughout the analyses and writing of this manuscript: Dr. Abdelaziz Matani, Mr. Melbin John, and Mr. Omar Al-Omar. Without their support, this paper would not have materialized.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Swan HJ, Ganz W, Forrester J, Marcus H, Diamond G, Chonette D. Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter. The New England Journal of Medicine 1970;283:447-51.  Back to cited text no. 1
Tuman KJ, McCarthy RJ, Spiess BD, DaValle M, Hompland SJ, Dabir R, et al. Effect of pulmonary artery catheterization on outcome in patients undergoing coronary artery surgery. Anesthesiology 1989;70:199-206.  Back to cited text no. 2
Dalen JE, Bone RC. Is it time to pull the pulmonary artery catheter? JAMA 1996;276:916-8.  Back to cited text no. 3
Squara P, Fourquet E, Jacquet L, Broccard A, Uhlig T, Rhodes A, et al. A computer program for interpreting pulmonary artery catheterization data: Results of the European HEMODYN resident study. Intensive Care Med 2003;29:735-41.  Back to cited text no. 4
American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Practice guidelines for pulmonary artery catheterization: An updated report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Anesthesiology 2003;99:988-1014.  Back to cited text no. 5
Harvey S, Harrison DA, Singer M, Ashcroft J, Jones CM, Elbourne D, et al. Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): A randomised controlled trial. Lancet 2005;366:472-7.  Back to cited text no. 6
Wiener RS, Welch HG. Trends in the use of the pulmonary artery catheter in the United States, 1993-2004. JAMA 2007;298:423-9.  Back to cited text no. 7
Sandham JD, Hull RD, Brant RF. The pulmonary artery catheter takes a great fall. Crit Care Med 1998;26:1288-9.  Back to cited text no. 8
Pinsky MR, Pulmonary artery occlusion pressure. In: Pinsky MR, Brochard L, Mancebo J, Editors. Applied Physiology in Intensive Care Medicine, 1st ed. Berlin - Heidelberg: Springer; 2012; p. 49-56.  Back to cited text no. 9
Vincent JL, Dhainaut JF, Perret C, Suter P. Is the pulmonary artery catheter misused? A European view. Crit Care Med 1998;26:1283-7.  Back to cited text no. 10
IBM Corporation. IBM SPSS Statistics 20 Core System User's Guide; 2011.  Back to cited text no. 11
Iberti TJ, Fischer EP, Leibowitz AB, Panacek EA, Silverstein JH, Albertson TE. A multicenter study of physicians' knowledge of the pulmonary artery catheter. Pulmonary Artery Catheter Study Group. JAMA 1990;264:2928-32.  Back to cited text no. 12
Gnaegi A, Feihl F, Perret C. Intensive care physicians' insufficient knowledge of right-heart catheterization at the bedside: Time to act? Crit Care Med 1997;25:213-20.  Back to cited text no. 13
Ahrens TS. Is nursing education adequate for pulmonary artery catheter utilization? New Horiz 1997;5:281-6.  Back to cited text no. 14
Johnston IG, Fraser JF, Sabapathy S, Kruger PS. The pulmonary artery catheter in Australasia: A survey investigating intensive care physicians' knowledge and perception of future trends in use. Anaesth Intensive Care 2008;36:84-9.  Back to cited text no. 15
Binanay C, Califf RM, Hasselblad V, O'Connor CM, Shah MR, Sopko G, et al. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: The ESCAPE trial. JAMA 2005;294:1625-33.  Back to cited text no. 16
Ronald KL. Medical device surveillance: Gender differences in pulmonary artery rupture after pulmonary artery catheterization. J Womens Health 2003;12:931-5.  Back to cited text no. 17


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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