Effect Of Skin Glue Application On PIVC Failure In Emergency Department Patients

Background

Discuss about the Critical Evaluation Tool Template.

Critical appraisal involves systematic evaluation of a research study to determine the extent to which the study findings are trust-worthy, appropriate as well as relevant (Merriam-Webster, 2015). This report scrutinizes both the merits and demerits of the study methods with its applicability in healthcare practice. According to Baker (2014), various critical evaluation models can be used to critique a study and evaluate a quantitative research-study that includes critical appraisal-skill program (CASP), CONSORT, Polit tools, JADAD score, Parahoo and Rees model.

The given study was published in Annals which is an international, peer- reviewed journal that is released by American College of Emergency Physicians; with a credit of being the largest circulating emergency medicine journal with over 33,000 subscribers. Annals that are published in United-States has highest impact-factor: 5.008, journal-rank:1.942 with highest citation-years (9.6 years) than immediate competitor (5.1 years) (Callaham, 2017). They publish original articles, research-reports and facts in emergency medicine. These informations suggest that Annals are highly regarded journal that assures me to utilize the study-evidences in my clinical practice confidently to provide quality patient-care.

The authors Bugden, Scott, Clark, Johnstone & Shean are well experienced in emergency medicine in Caboolture hospital, Queensland with first four from the applied health-related economics centre and Menzies’s health institute, Griffith University. Author Mihala has published 29 research-articles, 101 study-citations; Fraser with 462 research-articles, 3,697 study-citations while Rickard with 191 research-articles and 2,231 study-citations. This study was conducted in the Caboolture hospital, Queensland. The author informations give me enough confidence to utilize these study findings in my practical area to minimize PIVC failure.

The researchers have given a clear, concise, accurate title that is consistent with the text. It stimulates an appropriate perception about the study’s basic nature (Boswell, n. d.). Their objective as ‘to investigate the effect of applying skin-glue with regular PIVC-care in minimizing the PIVC failure-rate’ is clear, adequate as well as achievable. The abstract condenses the study-problem, objectives, study-methodology, sample-descriptions, findings, conclusions and recommendations, as suggested by Iverson (2014). They have given recent, relevant, comprehensive and well-organized literature-review. They have only quoted studies to show the effect of skin-glue in minimizing infection but not for PIVC-occlusion and other causes. Few studies comparing the effect of skin-glue and other methods could have been included.

They have used Randomized-Controlled Trial (RCT) which is a true experimental quantitative design that is characterized with manipulation (skin-glue application with standardized PIVC-care), control group (receiving only standardized PIVC-care) and randomization (random assigning) (THS, 2015). This design helps to compare 2 or more interventional measures and also assists in drawing causal inferences between variables and renders strongest evidence (Polit, 2016). They have given one research question (purpose-statement) as ‘Does the application of skin-glue to adhere PIVC-line improve PIVC failure-rates as compared to standardized securement?’, which is clearly stated (Boswell, n. d.).

Study Objectives

According to Limm (2013), at-least 80% of the patients admitted in hospital requires PIVC insertion with majority in EDs in which 33%- 69% fails prematurely due to inadequate PIVC fixation causing dislodgement, micro-motion or site-infection (Marsh, 2015). PIVC failure can interfere with IV and medication therapy which may increase cost and patient discomfort. Hence, this large trail in ED setting can rule-out the effect of skin-glue with standard-securement rather than current best-practice.       

They have given an appropriate hypothesis to translate the study question into an expected outcome as ‘the skin-glue application can minimize the failure of PIVC at 48 hours’, which is scientific hypothesis that tests the relationship between skin-glue and PIVC failure-rate (Polit, 2016). They utilized single-sited, 2-armed, RCT to select 360 patients having 380 PIVC-insertions with the help of randomizer software for clinical-trial and were randomly allocated into control and experimental groups in 1:1 ratio (unblocked/unmasked). The control group received standardized PIVC-securement while the experimental group received single drop of cyanoacrylate skin-glue at PIVC’s hub and insertion-site to stick the PIVC in patient’s arm along with standardized PIVC-care with tape and dressing based on the Queensland’s guidelines (2015) and were analyzed for primary & secondary outcomes.

Target population is an entire population set in which the researcher is interested in proposing the study and in generalizing the research-findings (THS, 2015). Here, thay have selected the adult-patients being admitted in the Emergency department (ED) of Caboolture Hospital having PIVC-insertion as target population. Their setting was Caboolture Hospital, a Community hospital; 50km away from Brisbane’s north receiving 52,000 ED patients/ year. The samples that are the subset of population were recruited by 3 ED-research nurses for 16 hours/day in a week, as given by Polit (2016). They included participants aged 18/above years, having patent upper-limb PIVC, inserted by ED-nurses/clinicians and those consented. The samples allergic to adhesives, phlebitis, infection and/or thrombosis in PIVC-insertion, unwilling, anxious and non-English speaking were excluded. They have randomly allotted 174 PIVC-patients in both standard-care and skin-glue group by Randomizer-software.

Ethics are the set of rules that governs the degree to which the ethical, moral, legal and/or professional values are followed in a study (Polit, 2016). They got approval from the ethics-committee of the hospital’s human-research and have registered the trial in the Clinical-Trial registry of Australia & New-Zealand. The text suggests that they have got written consent from all the participants, which assures confidentiality and patient’s rights (DH, 2014).  

Study Design

Fink (2013) stated that data collection is a phenomenon by which the data is collected to address the study-problem. They have gathered the demographic and confounder details at the time of enrollment by a self-structured questionnaire with variables as age, gender, medication-history, PIVC-insertion (site, limb, person-inserted & gauge size), hours from PIVC-insertion to intervention and follow-up.

They have evaluated their primary study-outcome of measuring the PIVC failure within 48 hrs of insertion (regardless of cause) by direct-visualization (hospitalized-patients) or telephoning (discharged PIVC-patients) with gathering data about the experiencing features of PIVC-failure at 48 hrs or more. They have investigated their secondary study-outcomes by evaluating the individual modes of PIVC failure as site-infection, phlebitis, PIVC-occlusion, and/or PIVC-dislodgement through direct-observation, chart-review as well as structured-questionnaire. One of the three research nurses, well experienced in ED has collected data by these means appropriately.

Bugden et al (2016) has explained only about the data collecting method but not about the method of measuring data. They have stated that they have analysed the site-infection, PIVC-occlusion, phlebitis and PIVC-dislodgment variables but they failed to mention their method of grading these variables. The measurement instrument used should be valid as well as reliable to avoid bias (Fink, 2013). They haven’t mentioned the instrument’s validity and study-reliability assessment anywhere in the text. Though, the questionnaires were referenced from the study by Rickard (2012), the lack of measurement validity and reliability undermines the study-findings.

Bias is defined as any influence that distorts the study’s results and undermines study-validity (Fink, 2013). Blinding/masking helps to control bias in which the participants were prevented from reaching the information of study-participants, interventional aspects and/or researchers/observers (Polit, 2016). The text suggests that they have not blinded the participants as well as research ED-nurses after their allocation because of their intervention’s nature with subtle skin-glue color and appearance that are exhibited at the interventional & follow-up period which is acceptable.

The data analysis that involves organizing and analysing the gathered information by using statistical measures as descriptive and inferential methods is applied in this study (Polit, 2016). They have done an in-depth data analysis as per their study-outcomes as well as tested the study-hypothesis. Descriptive analysis that includes mean and percentages were used to describe and summarize data while inferential statistics that includes p-value and point- estimation was used to draw inferences between variables (Newcombe, 2012). Absolute differences between outcome PIVC failure-rates (primary & secondary) were drawn at the confidence intervals of 95% by point estimation and they have declared the statistical significance at p<0.05. They have efficiently managed the follow up sample loss (0.83%) by excluding them from data analysis to eliminate bias.

Study Population and Sampling Method

The results were expected and have completely presented their findings based on objectives (Polit, 2016). Their primary analysis indicates that the failure of PIVC was statistically (10%) lowered in experimental (17%) as compared to control (27%) group signifying a statistical-difference (CI95%:–18% to –2%; p=0.02) which is less than p<0.05 and so the statistical study-hypothesis was accepted. Their secondary analysis indicates that the PIVC-dislodgement was significantly (7%) lowered in experimental (7%) than control (14%) group at CI95%:–13% to 0%, p=0.04 that is less than p<0.05 and hence the hypothesis was accepted as supported by HospiMedica (2016). The rate of phlebitis (CI95%:–5% to 3%) and occlusions (CI95%:–8 to 4%) in experimental was lower than control group but wasn’t statistically-significant while no site infection was noted in both groups and hence statistical-hypothesis was partially rejected.   

No suggestions were found allowing others to propose similar study but they have given their intention to propose cost-benefit study in the future. They recommend nurses to apply skin-glue along with standard-care to reduce PIVC-failure as It is a simple and quick method to be easily practiced in busy ED.

Conclusion

Bugden (2016) has concluded that the application of skin-glue adhesives with the standardized PIVC-care as suggested by the PIVC guidelines of Queensland (2015) can reduce the PIVC failure-rates in adult-patients particularly in busy emergency settings. If the failure rates of PIVC are minimized, the ED-patient values will be promoted by eliminating un-needed cost, time, material and man power expenses. Applying the skin glue will enhance comfort of patient, promote their outcomes and will minimize the admission numbers due to the complications of PIVC failure (HospiMedica, 2016). They suggests that the use of adhesive skin glue will promote attachment of PIVC-line with the patient’s skin, thus avoiding unnecessary dislodgement, phlebitis, infection and occlusions which may interrupt the flow of medications. According to Stuart (2013), about 0.1% of the patients who suffered with PIVC failure may develop sepsis, which endangers the patient’s life adversely, which can be avoided by using adhesive skin glue to PIVC-site.

Nursing is all about providing essential care to all the patients irrespective of caste, creed, race and colour in varied settings ranging from basic care to critical care (Douglas, 2012). It involves rendering basic front-line care to the clients specifically in the busy emergency departments. Nurses should render quality nursing-care to the client in-accordance with their own values, beliefs and ethics. According to Boswell (n. d.), all the nurses should undertake critical appraisal of varied studies to evaluate its applicability in practice, thus enhancing evidence based nursing-practice.

Ethics and Data Collection

The nurses should render care within their ethical principles which is a set of moral values what all the nurses are expected to follow (Douglas, 2012). The nursing care rendered to the patients should not induce any harm to the patients or families and should impose some form of benefit to the clients based on the ethical-principle of beneficence (Polit, 2016). Nursing care should not inculcate any form of harm and/or any pain/discomfort to the clients that includes physical harm or injuries, psychological harm (stress, anxiety), social harm (lack of social support) as well as financial harm (lack of financial support or loss of wages), which comes under the principle of maleficience (Polit, 2016). The care rendered should not damage or hurt a person’s self-dignity, which is based on the principle of justice. Hence, evidence based nursing care is given with greater importance to protect the patient life.

The professional nurses must strive to render effective holistic-care to the patients by preventing illness, improving and protecting the health of the people (Douglas, 2012). It indicates that the nurses should take the responsibility to protect the ED-patients from unnecessary harm of PIVC failure causing site-infections that includes cellulitis/pus formation, phlebitis, vein irritation, pain/discomfort, swelling/ redness, PIVC-occlusions with PIVC-dislodgements (fluid extravasations/accidental PIVC-removal) (Aymes, 2016). The nurses should strive to propose more studies related to the effect of skin-glue adhesives in preventing PIVC failures to provide evidence-based care.

The nurses in the ED have to insert PIVCs to save the patients by starting treatment strategies. Studies suggests that majority of the ED patients requires IV-infusions to initiate immediate life-saving measures but nearly 33% to 69% of these insertions prematurely fail due to inadequate fixations causing pain, dislodgment, extravasations, discomfort, etc that affects the patient’s value severely (Marsh, 2015). It can influence the emotions of the ED-patients as it may necessitate increased expenses of the insertion of PIVCs because of frequent PIVC-failures, unnecessary expenditure due to repeated hospital admissions to manage the complications of premature PIVC-failures as occlusions, dis-lodgments, phlebitis/others (Edwards, 2014). The PIVC-failures can interfere with the management therapies as hydration, antibiotic and/or analgesic therapies. This can affect the physical, emotional and societal values of patient and the family-members as it may cause unnecessary hospital costs, fear and depression.

Stuart (2013) has also supported that the PIVC-failure increases healthcare expenditure as increased staff-time, more length of hospital-stay and adverse-event management. Hence, practicing the skin-glue with standard-care in PIVC by nurses will enhance patient’s comfort and also avoids patient harm within ethical principles, thereby promoting quality-care (ACSQHC, 2013). This critique helps me to generate best practices in PIVC-care so as to be utilized in my practical setting.

References

ACSQHC- Australian Commission on Safety and Quality in Health Care. (2013). Literature Review: Medication Safety in Australia. ACSQHC, Sydney.

Aymes, S. (2016). Skin Glue Reduces IV Failure Rate in the Emergency Department. Retrieved from https://www.acepnow.com/skin-glue-reduces-iv-failure-rate-in-the-emergency-department/

Baker, K. (2014). How to… make critiquing easy: The Royal College of Midwives. Retrieved from https://www.rcm.org.uk/news-views-and-analysis/analysis/how-to%E2%80%A6-make-critiquing-easy

Boswell, C. (n. d.). Chapter-14: The research critique process and the evidence based appraisal process. Retrieved from https://samples.jbpub.com/9781284079654/9781284108958_CH14_Pass03.pdf

Bugden, S., Shean, K., Scott, M., Mihala, G., Clark, S., Johnstone, C., … Rickard, C. (2016). Skin glue reduces the failure rate of emergency department-inserted peripheral intravenous catheters: A randomized controlled trial. Annals of Emergency Medicine, 68, 196–201.https://dx.doi.org/10.1016/j.annemergmed.2015.11.026

Callaham, M. L. (2017). Annals Journal of Emergency Medicine: Official Journal of the American College of Emergency Physicians. Retrieved from https://www.journals.elsevier.com/annals-of-emergency-medicine

Department of Health- DH. (2014). Standard 1: Governance for Safety and Quality in Health Service Organisations: Quality and Rural Health, Victorian Government. Retrieved from https://www2.health.vic.gov.au/…/%7B66241E62-A6D5-471F-B193-8BACCD4E864.

Edwards, M. (2014). A pilot trial of bordered polyurethane dressings, tissue adhesive and sutureless devices compared with standard polyurethane dressings for securing short term arterial catheters. Crit Care Resusc,16, 175-183.

Fink, A. (2013). Conducting Research Literature Reviews: From the Internet to Paper. Retrieved from https://books.google.co.in/books?isbn=1483301036

HospiMedica. (2016). IV Drip Failure Reduced by Skin Glue Application. Retrieved from https://www.hospimedica.com/critical-care/articles/294767305/iv-drip-failure-reduced-by-skin-glue-application.html

Iverson, K.M. (2014). Women veterans’ preferences for intimate partner violence screening and response procedures within the Veterans Health Administration. Research in Nursing and Health, 37, 302-311

Limm, E. (2013). Half of all peripheral intravenous lines in an Australian tertiary emergency department are unused: pain with no gain?. Ann Emerg Med, 62, 521-525.

Marraim-Webster. (2015). Critique. Retrieved from https: www//learners dictionary.com/search/ Critique

Marsh. (2015). Securement methods for peripheral venous catheters to prevent failure: a randomized controlled pilot trial. J Vasc Access,16, 237-244.

Newcombe, R.G. (2012). Confidence Intervals for Proportions and Related Measures of Effect Size. Retrieved from https://books.google.co.in/books?isbn=1439812780

Polit, D.F & Beck, C.T. (2016). Nursing Research: Generating and assessing evidence for nursing practice. Lippincott Williams & Wilkins: New Delhi.

Queensland Government Department of Health. (2015). Centre for Healthcare Related Infection Surveillance and Prevention, Queensland Government Department of Health, Australia: Peripheral intravenous catheter (PIVC) guideline. Retrieved from https://www.health.qld.gov.au/publications/clinical-practice/guidelines-procedures/diseases-infection/governance/icare-pivc-guideline.pdf.

Rickard, C.M. (2012). Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomized controlled equivalence trial. Lancet, 380, 1066-1074

Stuart, R.L. (2013). Peripheral intravenous catheter–associated Staphylococcus aureus bacteraemia: more than 5 years of prospective data from two tertiary health services. Med J Aust, 198, 551-553.

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