Abstract
Introduction: Healthcare-associated infections remain a major patient safety concern in intensive care units, particularly among mechanically ventilated patients who are exposed to invasive procedures and prolonged critical illness. Despite the availability of international infection prevention guidelines, adherence to infection control standards in routine ICU practice remains inconsistent, especially in resource-limited settings.
Objective: This study aimed to evaluate compliance with infection control standards in the care of mechanically ventilated adult patients using a structured observational audit approach.
Methods: A non-participant observational audit was conducted in adult intensive care units of governmental and private hospitals in the Hebron Governorate, Palestine. Compliance was assessed using a structured checklist derived from international guidelines. A total of 712 care observations involving 158 ICU nurses and 142 mechanically ventilated patients were recorded across multiple shifts. Compliance scores were categorized as poor, moderate, or good. Non-parametric statistical tests examined associations between nurses’ characteristics and compliance levels.
Results: Compliance varied across domains. High adherence was observed for proper disposal of contaminated materials (90.1%), closed suction system use (85.2%), and head-of-bed elevation (83.1%). Lower compliance was noted for oral care (54.9%), aseptic suctioning (62.7%), and hand hygiene before patient contact (67.6%). Overall, 41.1% of nurses demonstrated good compliance, while 13.9% exhibited poor adherence. Higher compliance was significantly associated with private hospital employment, advanced education, ICU experience, and prior infection control training (p < 0.05).
Conclusion: Compliance was inconsistent, with gaps in technique-sensitive practices requiring targeted quality improvement strategies.
References
1. World Health Organization. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva: WHO; 2016. Available from: https://apps.who.int/iris/handle/10665/251730
2. Papazian L, Klompas M, Luyt CE. Ventilator-associated pneumonia in adults: a narrative review. Intensive Care Med. 2020;46(5):888–906.
doi:10.1007/s00134-020-05980-0
3. Ranzani OT, et al. Epidemiology of mechanical ventilation and outcomes. Lancet Respir Med. 2022;10(8):779–792.
doi:10.1016/S2213-2600(22)00062-5
4. Rosenthal VD, et al. International Nosocomial Infection Control Consortium report, 2015–2020. Am J Infect Control. 2023;51(5):652–660.
doi:10.1016/j.ajic.2022.11.008
5. Centers for Disease Control and Prevention. Guidelines for preventing healthcare-associated infections. Atlanta: CDC; 2023. Available from: https://www.cdc.gov/hai
6. Klompas M, et al. Strategies to prevent ventilator-associated events in acute care hospitals. Infect Control Hosp Epidemiology. 2022;43(6):687–713.
doi:10.1017/ice.2021.363
7. Allegranzi B, et al. Burden of endemic health-care–associated infection in developing countries. Lancet. 2011;377(9761):228–241.
doi:10.1016/S0140-6736(10)61458-4
8. Qtait M, Alqaissi N, Jaradat Y. Assessment of Nurses’ Knowledge and Behavior Toward Preventing Central Line-Associated Bloodstream Infections in Intensive Care Units and Dialysis Units. Sage Open Nursing. 2025;11. doi:10.1177/23779608251402958
9. Majid S, et al. Adherence to infection prevention practices among nurses. J Clin Nurs. 2021;30(15–16):2208–2219.
doi:10.1111/jocn.15743
10. Polit DF, Beck CT. Nursing research: generating and assessing evidence for nursing practice. 11th ed. Philadelphia: Wolters Kluwer; 2023.
11. Alqaissi N, Qtait M. Knowledge and practices of ICU nurses related to prevention of ventilator-associated pneumonia. SAGE Open Nurs. 2025;11:23779608251349956.
doi:10.1177/23779608251349956
12. Lizarondo L, et al. Barriers and facilitators to guideline implementation in nursing. Int J Nurs Stud. 2023;139:104405.
doi:10.1016/j.ijnurstu.2022.104405
13. Saunders H, Evans J. Organizational influences on infection prevention compliance. J Nurs Manag. 2024;32(1):15–23.
doi:10.1111/jonm.13871
14. Qtait M. Systematic Review of Time Management Practices Among Nurse Managers. AJNM [Internet]. 2023 Aug. 3 [cited 2025 Dec. 28];25(2):11 pages. Available from: https://unisapressjournals.co.za/index.php/AJNM/article/view/13507
15. Qtait M, Alarab S. Definition and types of time management obstacles for nursing. International Journal of Innovative Research in Medical Science. 2018;3(10):2243-7. DOI:10.23958/ijirms/vol03-i10/451
16. World Bank. Improving health system performance in fragile settings. Washington DC: World Bank; 2022.
17. Qtait M, et al. Nurses’ knowledge and behavior toward preventing healthcare-associated infections. SAGE Open Nurs. 2025;11:23779608251402958.
doi:10.1177/23779608251402958
18. Alkubati SA, et al. ICU nurses’ knowledge and practices regarding infection control. J Infect Public Health. 2023;16(2):211–218.
doi:10.1016/j.jiph.2022.10.012
19. Polit DF. Bias in self-reported nursing research. Res Nurs Health. 2021;44(2):241–248. doi:10.1002/nur.22101
20. Qtait M. Nurses’ Knowledge, Attitudes, and Implementation of Evidence-Based Practice Comparative Study. Sage Open Nursing. 2025;11. doi:10.1177/23779608251343611
21. Ivers N, et al. Audit and feedback: effects on professional practice. Cochrane Database Syst Rev. 2012;(6):CD000259.
doi:10.1002/14651858.CD000259.pub3
22. Baier C, et al. Observational audits of infection control compliance in ICUs. Am J Infect Control. 2020;48(8):921–927.
doi:10.1016/j.ajic.2019.11.013
23. World Health Organization. Hand hygiene technical reference manual. Geneva: WHO; 2009.
24. Alqaissi N, Qtait M. Knowledge, Attitudes, and Practices of Intensive Care Unit Nurses Regarding Oral Care for Intubated Patients in Hebron Hospitals, Palestine. Sage Open Nursing. 2025;11. doi:10.1177/23779608251368041
25. von Elm E, et al. The STROBE statement. Lancet. 2007;370(9596):1453–1457. doi:10.1016/S0140-6736(07)61602-X
26. Labeau SO, et al. Evidence-based guidelines for airway management in ICU. Intensive Crit Care Nurs. 2019;53:100732.
doi:10.1016/j.iccn.2019.03.006
27. McHugh ML. Interrater reliability: the kappa statistic. Biochem Med. 2012;22(3):276–282. doi:10.11613/BM.2012.031
28. McCambridge J, et al. Systematic review of the Hawthorne effect. J Clin Epidemiol. 2014;67(3):267–277. doi:10.1016/j.jclinepi.2013.08.015
29. Aloush SM, Alsaraireh FA. Compliance with infection prevention bundles. J Infect Public Health. 2018;11(4):548–553.
doi:10.1016/j.jiph.2017.10.003
30. Pittet D, et al. Evidence-based model for hand transmission during patient care. Lancet Infect Dis. 2006;6(10):641–652.
doi:10.1016/S1473-3099(06)70600-6
31. Erasmus V, et al. Systematic review of hand hygiene compliance. Infect Control Hosp Epidemiol. 2010;31(3):283–294.
doi:10.1086/650451
32. Goldman J, et al. Leadership and infection prevention culture. BMJ Open. 2021;11:e043516. doi:10.1136/bmjopen-2020-043516
33. Klompas M, et al. Preventing ventilator-associated events. Clin Infect Dis. 2022;75(3):e718–e727. doi:10.1093/cid/ciac097
34. Sole ML, et al. Airway management and infection risk. Crit Care Nurse. 2020;40(2):e1–e10. doi:10.4037/ccn2020456
35. Rello J, et al. Airway management and infection transmission. Chest. 2021;159(3):1094–1102. doi:10.1016/j.chest.2020.09.254
36. Labeau SO, et al. Education and infection prevention compliance. Intensive Crit Care Nurs. 2018;45:65–72.
doi:10.1016/j.iccn.2017.12.005
37. Melnyk BM, et al. Evidence-based practice and outcomes. Worldviews Evid Based Nurs. 2023;20(1):5–14.
doi:10.1111/wvn.12615
38. Sham R, et al. Simulation-based infection control training. Nurse Educ Today. 2023;120:105640.
doi:10.1016/j.nedt.2022.105640
39. World Medical Association. Declaration of Helsinki. JAMA. 2013;310(20):2191–2194.doi:10.1001/jama.2013.281053
40. Sachan A, Manu S. Leadership and infection control. J Hosp Infect. 2022;124:45–53. doi:10.1016/j.jhin.2022.02.015
41. Alqaissi N. Nurses’ Knowledge and Behavior in Hospitals Regarding the Prevention of Central Line-Associated Bloodstream Infections: A Systematic Review. Sage Open Nursing. 2025;11. doi:10.1177/23779608251347119
42. Aburayyan L, Ozturk C, Qtait M. Enhancing Pediatric Nurses’ Knowledge, Attitude, and Practice Regarding Health Care-Acquired Infections: A Quasi Experimental Study. Disaster Medicine and Public Health Preparedness. 2025;19:e159. doi:10.1017/dmp.2025.10088
43. Qtait M. and Alekel K., Prevalence and Epidemiological of Burns in Hebron, Palestine, Research Journal of Applied Sciences. (2019) 2, no. 4, 06–10, https://doi.org/10.3619/SJASR.1000224.
44. Ayed A., Eqtait M., Fashafsheh I., Ali A. (2015). Knowledge & compliance of nursing staff towards standard precautions in the Palestinian hospitals. Advances in Life Science and Technology, 36, 21–30. http://repository.aaup.edu/jspui/handle/123456789/1247
45. Feras Tomazeh & Majd Mustafa Issa & Aseel Yasser AL-Atrash & Hadeel Muhammad Greeab & Atheer Muhammad Tous & Muhammad Areef Maree, 2025. "Nurses’ Knowledge Toward Preventing Central Line-Associated Bloodstream Infections in Intensive Care Units," Nursing Depths Series, AG Editor (Argentina), vol. 4, pages 283-283.
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Copyright (c) 2026 Taymaa Al-Tloul, Aya Awad, Zakari Ahmad, Bayan Shalaldeh, Nassrallah Sarhan, Maram M. Aladam (Author)