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Structuring the Study

Discuss about the Critical Evaluation Report on Effect of Skin Glue.

Their mention about the study by Limm (2013) stating 80% of hospitalized patients requiring PIVC insertion among which 33% to 69% of them fails due to infections, phlebitis, occlusions and dislodgment is adequate (Marsh, 2015). Their mention about the effect of skin glue in securing central-venous, peripheral-arterial and epidural catheters as compared to the standard dressings; clearly support this study (Edwards, 2014). The authors have clearly shown their motive for this research study by quoting that there is no quality evidence in skin securement as well as there is uncertainty in practicing best methods to secure peripheral intravenous catheters and hence they have proposed this study. They have mentioned most current, relevant, comprehensive and recent citations (except few). There are no evidences to describe about the effect of skin glue as compared to other securing methods. Moreover, they have only mentioned about the effect of skin glue in minimizing infection (Simonova, 2012) but not about its effect in reducing occlusions, infections and dislodgment. The researchers have used one-site, two-arm and Randomized-Controlled trail to randomize 360 adult patients with 380 PIVC through randomizer clinical-trial software to allot them to both the groups in a ratio of 1:1 (without blocking or masking). In this study, the standard (control) group was given with standard catheter care (PIVC securement with poly-urethane material) whereas the skin glue (experimental) group was kept with one drop of (cyanoacrylate) skin glue both at the PIVC insertion site and catheter’s hub to adhere the catheter in patient’s skin along with PIVC tape and dressing as per standard-care guidelines of Queensland (2015) an was analyzed both primary and secondary outcomes. They have given a logical scientific hypothesis that follows the original problem of the study as ‘the application of skin glue in the PIVC inserted site in ED would decrease its failure at 48 hours’. They have demonstrated their interest in examining the relationships between skin glue and PIVC failure rate.

Their description of sample is clear. Trained ED research nurses (1 of 3) have determined 360 samples having 380 PIVCs for 16 hours/day for one week through randomization by software and determined 195 samples in standard-care group and 185 in skin-glue group. They have included the samples with age (<18) having patent PIVC in upper extremities- inserted by physicians/nurses (ED) in intact skin. They have selected patients who have signed written informed-consent (Richard, 2012). The research nurses have selected the participants with patent PIVC line by infusing 10 ml of 0.9% normal saline solution. They have excluded the patients with known allergies to securement materials, presence of infection, phlebitis (upper extremities), venous-thrombosis and patients prone for PIVCs removal (semi-conscious/agitated patients) and people who doesn’t know English; without interpreters.

Sample

They have collected data by using a questionnaire for primary and secondary outcomes by 1 of 3 research nurses. They have collected basic-demographic and possible-confounder data from the samples at enrollment with characteristics as age, sex, intake of medications (immuno-suppressant, antibiotics, and anticoagulants), no. of PIVC insertions, limb of insertion, physicians/nurse inserted PIVC, gauge-size of PIVC and time between PIVC insertion and interventional and follow-up time. They have selected few patients with multiple-devices yet has analysed their first inserted PIVC. They have assessed the primary-outcomes through directly visualizing (in-patients) or assessing through telephoning (discharged patients) at 48/more hours with characteristics as site-infection with cellulitis and/or pus, phlebitis with pain, tenderness, swelling/redness, occlusions, accidental removal/dislodgement of PIVC with extravasations (O’Grady, 2011). They have assessed the secondary outcomes with individual aspects of PIVC failure through direct-visualization, chart-reviewable with standardized-questionnaire. They have appropriately discussed about data collection. They have not given about the origin of study-instruments but mentioned about their reference in study by Rickard (2012). They have collected data through self-framed questionnaire. They have concisely discussed about the study-instruments but the method by which they graded the secondary outcomes was not given. There is no evidence for their validity and reliability assessment for the measurement instruments in the research text. They have not discussed about the ethical issues but only given about the financial issues.

The follow-up was adequate to make the results credible as they have excluded the outcome data of patients those who have loosed during follow- up. There was minimal follow- up loss with only 5 lost in standard-care and 6 in skin-glue group with 2.8%/PIVC and 0.83%/ patient loss that is equal in both groups. In addition to that, their data analyses with differences in outcomes at 95%-CI with the statistical significance at a level of p<0.05 was appropriate. Blinding is the process by which the study samples, researchers or interventional agents should be prevented from having information that may cause bias (Polit, 2016). They could not blind or mask the samples as well as research nurses after allocation due to the nature of this intervention with same glue colour and appearance both at the experimental and follow-up time (Richard, 2012). The data analysis of primary outcomes with failure rate of PIVC at 48 or more hours shows that the difference between the standard securement as well as the skin glue groups was found to be statistically significant at 95%-CI–18 to –2%; p=0.02. The data analysis of secondary outcomes shows that the difference in catheter-dislodgement between standard and skin glue groups was statistically significant at 95% CI–13 to 0%; p=0.04. The rate of phlebitis was noted to be reduced in skin glue as compared to standard group at 95%-CI –5% to 3% indicating that there is no statistical significance between these groups. The rate of occlusion was identified to be lowered in skin glue patients at 95% CI–8 to 4% than standard securement group depicting lack of statistical significance whereas infection rate is nil both groups. In this study, inferential statistics was adopted which suggests the applicability of study results in larger population (Polit, 2016). They have employed both types of inferential statistics with p- as well as point estimation in this study. The primary data analysis shows that the PIVC failure rate was statistically lowered in the skin glue group than standard securement group suggesting that the difference between both groups were statistically significant at p<0.05 level and hence statistical hypothesis was accepted. The secondary data analysis shows that the PIVC failure rate due to dislodgement was low in skin glue as compared to standard group suggesting that the difference is statistically significant (p<0.05) indicating that the hypothesis is accepted. Phlebitis and occlusion percentage was found to be lowered in skin glue group but not statistically significant while the infection rate was nil in both groups.

Data Collection

The study findings were expected with adequate informations in judging the results. They have clearly and completely stated their findings with percentages and dialogues in the text.The findings suggests that the failure rate of PIVC at 48 or more hours was statistically (10%) reduced in skin glue patients (17%) than that of standard securement patients (27%) at 95% CI –18% to –2%; p=.02. and the incidence of dislodgement was lowered (7%) in skin glue (7.0%) than standard securement group (14%) at 95% CI –13% to 0 (HospiMedica, 2016). Phlebitis and PIVC occlusions were found to be lowered in skin glue than standard group but not statistically significant and the infection rate was nil (0%) in both skin glue and standard securement group (Bausone-Gazda, 2010). The per-patient analysis of skin glue (n=170) and standard (n=179) groups indicates that the PIVC failure rate at 48 hours or more was noted to be 31 and 52 respectively. The PIVC failure rate of secondary outcomes by infection was 0 Vs 0, phlebitis was 9 Vs 5, occlusion was 20 Vs 14 and dislodgement was 25 Vs 12. These findings ensure that the application of skin glue with standard securement could minimize PIVC failure rate. The study findings could not be generalized to other settings as it was conducted only in ED and local-cultured patients. Its limitations include lack of description about the usage of 50% dextrose, potassium chloride, sclerotics, number of accesses of PIVC, lack of dwell time, etc which could be an important determinant in analyzing the failure rate. More than half of the patients in both the groups were discharged before 48 hours and hence they have collected informations about features of failure through telephone callings at home which may modify the results from that of in-patient through direct-visualization. They have mentioned that a cost-benefit analyses will done in the future to analyze the skin glue cost (Chico-Padron, 2011). They summarized that the skin glue could be applied to the insertion site of PIVC in ED so as to avoid its failure rate. They didn’t mention about allowing others to conduct similar study.

Conclusion

They concluded that mostly, this is the first Randomized- controlled trial study that has been proposed to investigate the usage of skin glue with standard securement methods that helps to adhere PIVC in the skin of emergency patients. The failure rate of PIVC in the standard securement group with 28% was supported by the study conducted by Marsh in 2015. The researchers suggest that the skin glue securement could be used along with standard catheter care guidelines (2015) to reduce failure rate.  Further the application of skin glue is simple and easy. This reduction in failure rare will minimize cost, money and effort of the patients and staffs and also avoids sepsis, which occurs in almost 0.1% of PIVC failure cases that costs their life (Stuart, 2013). 

Data Analysis

Nurses have to constantly work to get solutions, choices as well as outcomes for clients care. They have to develop best evidence based knowledge in the worldwide to continuously promote and enhance nursing care. The Nurses with Midwives councils of most of the countries incorporates promoting nursing as well as research based on the contemporary practices with and educational developments in their objective. Moreover, as the nurses are the primary care takers of all the patients in the clinical and community settings of all age groups, they have to be well-versed in the contemporary practices of nursing care. The nurses have to analyze the best evidences available in the research studies so as to utilize in their clinical practice (ANA, 2010). As the science and technology advances, the nurses have to adopt the newer styles of nursing care to the patients so as to provide a quality of care to the patients. The nurses have to provide a quality care in accordance to ethical principles by inculcating some benefit to the patients rather than harm (Polit, 2016). The nurses should play a great role in preventing diseases and promoting health of the people which illustrates that the nursing practice should not inculcate harm to the people (ICN, 2010).

The above study describes the clear and adequate finding about the application of skin glue along with a standard catheter care in the insertion site of PIVC to avoid failure of PIVC. As the nurses have prime responsibility in inserting PIVC (80%) in hospitalized patients and most of the insertions are made in the ED, they should also be efficient in securing PIVCs from failure (Limm, 2013, Marsh, 2015). The nurses have to develop the professional knowledge with competence by rendering nursing care based on the recent evidence and provide best practice that is applicable as well as available with validated research. As these study findings are also supported by other studies and is also published in Annals, the nurses can use skin glue to secure PIVCs with standard care by Queensland (2015).  

The nurses should be expertise in protecting clients from PIVC failure (phelibitis, infections, dislodgement and/or occlusions) (Rebelem, 2016). PIVC failure often disrupts the administration of therapies as hydration therapy, antibiotic and analgesia. It also increases health-care cost, anxiety, depressiveness and discomfort to the patient (reinsertion) affecting the patient’s value adversely (Stuart, 2013). Moreover, it increases the health-care system costs including increased staffing time, consumables, prolonged length of hospital stay with adverse- event management, PIVC complications, PIVC complication funding- penalties and client’s complaint and satisfaction-based costs. Therefore, the nurses should secure PIVCs with skin glue based on this evidence to protect patent’s values and promote their comfort.   

References

ACEP. (2016). Annals of Emergency Medicine: American college of Emergency- Physicians. Retrieved from https://www.acep.org/annals

ANA. (2010). What is nursing?. Retrieved from https://www.nursingworld.org/Especially ForYou/StudentNurses/ What is nursingaspx

Aveyard, H. (2010). Doing a literature review in health and social care: a practical guide (second edition). Open University Press: Berkshire, England.

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

Bausone-Gazda, D et al. (2010). A randomized controlled trial to compare the complications of 2 peripheral intravenous catheter-stabilization systems: J Infus Nurs. 33: 371–84.

Chico-Padron, R.M et al. (2011). Comparative safety and costs of transparent versus gauze wound dressings in intravenous catheterization: J Nurs Care Qual. 26: 371–76.

Consolidated Standards of Reporting Trials (CONSORT). (2010). The CONSORT statement. Retrieved from www.consort-statement.org/consort-statement/overview0/

Critical Appraisal Skills Programme (CASP). (2010). Critical Appraisal Skills Programme. Retrieved from www.casp-uk.net/

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

Greenhalgh, T. (2010). How to read a paper: the basics of evidence-based medicine. (4th ed.). Wiley-Blackwell/BMJ Books: Oxford.

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

ICN (2010). The ICN definition of Nursing. Retrieved fromvhttps://www.ich.in/definition.htm

Limm, E.I et al. (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.

Marsh, N. (2015). Devices and dressings to secure peripheral venous catheters to prevent complications [review]: Cochrane Database Syst Rev. 6:CD011070.

O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis 2011; 52: e162–93.

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.

Rebelem. (2016). Should We Use Skin Glue to Secure Peripheral IVs: R.E.B.E.L. E.M. Retrieved from https://rebelem.com/should-we-use-skin-glue-to-secure-peripheral-ivs/

Simonova, G et al. (2012). Cyanoacrylate tissue adhesives—effective securement technique for intravascular catheters: in vitro testing of safety and feasibility: Anaesth Intensive Care. 40:460-466.

Stuart, R.L et al. (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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