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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: sarah.lewis@sydney.edu.au (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

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

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Infection, Disease & Health xxx (xxxx) xxx
useful to track trends over time or prior to any intervention
or education program [6].The KAP survey style was deemed
appropriate for this study design due to its versatility and
ability to be adapted to other MI specialties, demographics,
and scenarios. Surveys provide demographic data on an
individual level and are often aggregated at a cohort level.
MI departments in the Australian healthcare setting often
incorporate different roles, and the targeted participants
for this survey design were those specifically working in the
CT suite.
The inclusion of demographic data is important for KAP
surveys particularly if baseline data can then progress to
intervention [6]. Information pertaining to the participants’
workplace, education and experience provides a framework
for understanding the specific work system in which the
relationship between the HCW (such as a radiographer),
technology and tools, organisation, tasks, and environment
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-
geted interventional approach to HAI risk minimisation. The
CT suite is not immune to HAI, with transmissions previously
described in relation to the use of contrast enhanced CT
procedures [12,16e18]. Additionally, many radiographers
choose to specialise in CT, and hence the link between
experience, training and CT caseload as collected by de-
mographic questions supports opportunity for statistical
analysis.
Understanding specific CT suite ‘demographics’ offer
potential identification of CT specific areas of concern,
clarify areas for possible intervention and supports mapping
an area that has not previously been reported in literature,
such as procedural and human error in IPC related to IV
contrast delivery in MI departments [5,6,11,12,14].
Reviewing literature on IPC and compliance [16,17]
identified themes that contribute to non-compliance,
which was considered an important element of IPC sur-
veys in MI. The following themes of ‘risk desensitisation’,
‘workplace culture’, ‘workload’ and ‘physical safety’ were
identified as reasons for non-compliance to IPC. Exploring
these variations of compliance is necessary to understand
potential areas for breach of SP and increased HAI risk.
Methods
An expert reference group (ERG) was established to
develop the survey. This included a total of four Australian
registered Medical Radiation Practitioners (MRP) with
research qualifications: 2 (XX, XX) of the researchers have
current and extensive CT imaging experience as Diagnostic
Radiographers. A further two members of the ERG are
experienced MRP researchers in survey design in MI with
registration in Diagnostic Radiography (XX) and Radiation
Therapy (XX). A further three industry experts with expe-
rience in IPC and microbiome in clinical applications
related to radiology medical devices and healthcare regu-
lation were members of the ERG (see acknowledgments).
Survey development followed a sequential process of
survey foundation and study design. Study design included
identification of target demographics, question develop-
ment, and question response development (Fig. 1). The
3
survey foundation was undertaken in two stages: estab-
lishing the benchmark of standards and identifying a survey
style that facilitated exploration of IPC in the CT suite.
Survey foundation
Given that MI departments vary significantly, importance
was placed to identify an overarching document offering a
baseline for all subsequent standards. The National Health
and Medical Research Council (NHMRC) published the
Australian Guidelines for the Prevention of Infection in
Healthcare in 2019, providing the nationally accepted
approach for IPC in Australia [7], and hence became the
benchmarking resource for the survey. This approach is
recommended in the professional literature on survey
design [8], using existing literature, instruments and expert
reference documents.
Study design
Demographics
For this survey, the intention was to capture IPC in CT as
self-reported by qualified registered diagnostic radiogra-
phers. However, we acknowledge that other staff, such as
nuclear medicine technologists, radiology nurses, radiation
therapists, doctors, assistants, and wards people do work in
CT and may also be able to complete the survey with
modifications. Although students were not the target for
this survey construction, the questions could be applied,
with suitable modifications, to enrolled MRP students too.
Common social demographics were included in this survey,
such as working experience (years, position title), place of
work, caseload, and qualifications.
The CT suite demographic questions in our survey design
extended to capture information about how IV contrast and
power injector equipment is used in the clinical setting.
Question development
For question development, the ERG sought to provide def-
initions of knowledge and benchmarking practices, fol-
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
component parts (Table 1). This process was performed in
collaboration with the ERG, and the definitions from
sourced documents for this questionnaire were founded on
definitions of IV contrast provided by product information
from Bayer Australia [14] and patient use definitions were
defined by the NHMRC guidelines [7]. The Medical Radiation
Practice Board of Australia’s (MRPBA) Professional Capa-
bilities were also searched for conceptual best practice.
However, the professional capabilities expression related
to IPC is very broad in “protect and enhance patient/client
safety” with the enabling components stated as an expec-
tation to “identify and manage risk of infection, including
during aseptic procedures” [Domain 5.2] [15]. Domain 5.2
professional capabilities do not specifically mention
contrast administration or medical devices, but rather
contrast media is defined and expressed as a ‘medicine’
under Domain 2.8 (and the Key Terms Table) and radiog-
raphers are required to have the capability to “apply
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S. Hill, Y.A. Jimenez, D. Abu Awwad et al.

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].
Questions or concepts that were not relevant to the CT
suite from the NHMRC guidelines were not included or
removed from the survey after ERG consensus.
Identifying KAP questions
Combining the framework of the KAP style survey with the
benchmark of the national guidelines required multiple
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
altered to separately question participants knowledge of,
attitudes towards, and practice of the same concept.
Hence, each statement could be matched across the KAP
components and mapped to the NHMRC concepts explored
in this study (Table 2). This included changing key words to
change sentences from a knowledge statement to reflect an
attitude towards the statement, and then modifying the
statement to create an action statement to reflect
practice.
‘Risk desensitisation’ and ‘workplace culture’ were created
to explore known variations of compliance that had been
identified by other similar health professions [16,17]. Two
further concepts, ‘workload’ and ‘physical safety’, were
indirectly explored through the open-ended question to
capture unknown or unexplored themes.
Results
With the creation of the initial question bank, the ERG
reviewed the question bank and fine-tuned the questions
through consensus and experience. The final survey
included 77 questions. The complete survey is found in
Appendix 1. The result options of the survey questions
outlined in the methods section are outlined below. Table 3
summarises the results of the survey foundation and study
design.
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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Infection, Disease & Health xxx (xxxx) xxx
Table 1 Mapping ‘Truth’ statements related to contrast administration in CT with NHMRC guidelines [7].
Knowledge Statement
All patients are sources of infections
regardless of their diagnoses.
The use of gloves replaces the need
for hand hygiene.
Hand hygiene is indicated after
removal of gloves.
CT tubing causes no risk to healthcare
workers.
All Intravenous (IV) Contrast Injection
Equipment can be a source of
infection.
Disconnection and reconnection of IV
contrast administration sets does
not increase the risk of infection.
Transmission of infectious agents can
occur through hands that are in
contact with CT department
equipment.
The IV contrast injector is considered
a frequently touched surface for
infection transmissions.
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Truth NHMRC guidelines supporting Survey Question Number
Statement statement [7]
TRUE Standard precautions must be used 36, 47, 58, 70, 72
regardless of known or suspected
pathogens being transmitted via the
contract, droplet, or airborne route.
(p28)
FALSE It is recommended that routine hand 37, 48, 59, 69
hygiene is performed (before
touching pt., before a procedure,
after procedure or body substance
exp, after touching pt., after
touching pts surroundings. (p30)
TRUE Hand hygiene must also be performed 38, 49, 59, 60, 71
before putting on gloves and after the
removal of gloves. (p30)
FALSE Healthcare workers may be exposed 39, 50, 61
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)
TRUE While shared clinical equipment 40, 51, 61
comes into contact with intact skin
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)
FALSE Consider syringes or needles/canulae 41, 52, 62, 65, 71
as contaminated once they have been
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)
TRUE Transmission of infectious agents 42, 53, 72
from the environment to patients
may occur through direct contract
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)
TRUE Cleaning clinical surfaces including 43, 44, 54, 55, 66, 67
equipment should always occur
between patients or uses, regardless
of whether a surface barrier has been
used or not. (p65)
(continued on next page)
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S. Hill, Y.A. Jimenez, D. Abu Awwad et al.
Table 1 (continued )
Knowledge Statement Truth
Statement
The IV contrast injector is considered TRUE
a high-risk surface for infection
transmissions.
Hands must be washed with soap and TRUE
water after coughing, sneezing,
and/or using tissues.
Any fluids, including leaked IV TRUE
contrast are a source of infection
after the IV contrast has been
connected and/or disconnected to
the patient.
Note: NHMRC Z National Health and Medical Research Council. IV Z Intravenous. CT Z Computed Tomography.
[16]. The multi-selection responses allow respondents to
select any possible sources as a checklist, with an option to
select ‘other’, which prompted an open response. Given
the varied workplace environments and differing
requirements between the public hospital and private
clinic, it was important to understand how participants
acquired knowledge about IPC and contrast administration,
and if there was a noticeable difference in knowledge
sources between any demographic subgroups. See Appendix
1 for multi-selection options, which included work col-
leagues, policies, product guidelines, manufacturer guide-
lines, etc.
The knowledge questions were formed as closed ques-
tions from the Australian guidelines [7] and presented as
‘truth’ statements where the answer responses were
selected to be either ‘True’ or ‘False’. When the partici-
pant indicated a statement was true or false, they were
then assigned a correct or incorrect response to the ‘truth’
of that statement. The statements were posed in such a
way that not all correct responses were all true or all false.
Attitudes responses
Attitude responses were formed on a 5-point Likert scale.
These were scaled as ‘strongly agree’ to ‘strongly disagree’
with a neutral response at the mid-point. The core of the
statement from knowledge questions is maintained, with
the wording changed such that the statements were per-
taining to an individual’s attitude or the perception of an
attitude toward the statement.
Practice responses
These answer options were also in the form of a 5-point
Likert scale. The answer responses were modified to be
focused on the level of engagement or frequency of
NHMRC guidelines supporting Survey Question Number
statement [7]
Cleaning clinical surfaces including 43, 44, 54, 55, 66, 67
equipment should always occur
between patients or uses, regardless
of whether a surface barrier has been
used or not. (p65)
Hands must be washed with soap and 45, 56, 64, 68
water after coughing, sneezing, using
tissues, or after contract with
respiratory secretions or objects
contaminated by these secretions.
(p90)
Consider syringes or needles/canulae 46, 57, 61, 62, 65, 71
as contaminated once they have been
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)
practice of the statements. For example, the statement “I
use gloves to replace the need for hand hygiene” had the
response options of ‘always’, ‘frequently’, ‘occasionally’,
‘rarely’, or ‘never’. There were questions specifically
relating to the CT IV contrast power injector, where
response options were ‘between every patient’, ‘periodi-
cally during the day’, ‘once a day’, ‘a few times a week’,
‘once a week’, or ‘infrequently’.
Compliance responses
The survey was constructed to assist in exploring scenarios
where participants believed they would modify their
compliance of IPC practices. These areas were related to
workplace culture and risk desensitisation as previously
described by Morris and Jakobsen [17]. Both areas used 5-
point Likert scales from ‘strongly agree’ to ‘strongly
disagree’. The workplace culture statements used MI
appropriate terminology such as “my department” to
portray the CT suite environment in which participants are
working.
Open response question
The question “If I was to not adhere to standard and
transmission-based precautions, it is most likely when .”
was posed as the only completely open response question.
It is also the only question that encompasses IPC in its en-
tirety, including both SP and TBP [7]. This provides re-
searchers with the opportunity to discover their own blind
spots or biases regarding variations in attitudes and prac-
tice of IPC in the MI department. Given the complexity of
clinical decision making [16], the open response provides
participants with free text to discuss variations of what
they perceived to be accepted practice. This was the final
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
All patients are sources of infections
regardless of their diagnoses
The use of gloves replaces the need
for hand hygiene
Hand hygiene is indicated after
removal of gloves
CT tubing causes no risk to healthcare
workers
All IV Contrast Injection Equipment
can be a source of infection
Disconnection and reconnection of IV
contrast administration sets does
not increase the risk of infection
Transmission of infectious agents can
occur through hands that are in
contact with CT department
equipment
The IV contrast injector is considered
a frequently touched surface for
infection transmissions
The IV contrast injector is considered
a high-risk surface for infection
transmissions
Hands must be washed with soap and
water after coughing, sneezing,
and/or using tissues.
Any fluids, including leaked IV
contrast are a source of infection
after the IV contrast has been
connected and/or disconnected to
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.
Attitudes
I consider patients to be a source of
infection regardless of their diagnosis
I consider gloves an alternate to hand
hygiene
I consider hand hygiene to be
warranted after removing gloves
My workplace doesn’t consider
needleless connections of tubing as a
source of infection
I consider IV contrast injection
equipment a source of infection
The disconnection and/or
reconnection of IV contrast
administration increases infection
risk
I believe that the transmission of
infectious agents can occur through
hands that are in contract with CT
department equipment
My workplace considers the IV
contrast injector to be a frequently
touched surface for the spread of
infection
My workplace considers the IV
contrast injector to be a high-risk
surface for the spread of infection
I consider it good practice to wash my
hands with soap and water after
coughing, sneezing of using tissues.
I consider any fluids to be sources of
infection after the IV contrast has
been connected and/or disconnected
to the patient
Practice
I use standard precautions for all
patients as they are a source of
infection.
I use gloves to replace the need for
hand hygiene
I use hand hygiene after removing
gloves
I practice standard precautions when
dealing with needleless connections
of IV contrast tubing
I clean IV contrast equipment
I disconnect and reconnect the IV
contrast administration set for a
patient if required for the
examination
I practice standard precautions when
dealing with CT department
equipment
At my workplace, the IV contrast
injector is cleaned
At my workplace, the IV contrast
injector is cleaned
I always wash my hands with soap and
water after coughing, sneezing, or
using tissues.
I use standard precautions when
connecting and/or disconnecting the
IV contrast lines from the patient

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

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

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

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

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