Critical appraisal of a journal involves evaluating the research article systematically to determine its trust-worthiness, appropriateness and relevance to a particular context (Polit, 2016). Southern-Australian University has given various models for research critiquing as CASP (Critical-appraisal skill program), PEDro scale (Physiotherapy-evidence database), CONSORT, JADAD score, etc. The journal of Annals of Emergency-Medicine is an international journal that is published by the American-college of emergency physicians to improve the quality of medical-care. Annals are the largest circulating peer-reviewed journal in emergency- medicine with more than 33,000 subscribers. It has the highest impact-factor of 5.008 and is also cited longer than other emergency- medicine journals for 9.6 years as compared to 5.1 years of circulation of the competitor journal (Callaham, 2017). These informations about Annals motivate me to use this research in my practice confidently and provide quality-care. The authors Bugden, Scott, Clark, Johnstone and Shean are experts in the emergency-medicine field. The first four authors are from the Centre of applied health-economics, Menzies Health-institute (Queensland) of Griffith University. They are experienced in the NHMRC centre for research with excellence in nursing field and they have experience in Centre for health-practice innovations of Queensland. This study was conducted in Caboolture community hospital, Queensland at the north of Brisbane with 52,000 ED cases annually. The author’s contributions motivates me to use the given research findings confidently in my practice to reduce the peripheral-intravenous catheter failure.
The title is highly clear and congruent with the text. They have stated the objectives as ‘to evaluate whether the failure of peripheral-intravenous (IV) catheters could be minimised by the skin-glue application with standard securement which is clear, specific and achievable. They have stated the aims/hypothesis as ‘whether the failure rate of peripheral-IV catheters could be reduced by the skin-glue application and standardized securement and research design as single-site, 2-arm, non-blind, randomized-controlled trial and the samples of 360 adults with peripheral-IV catheter. They have given about the control (standard-securement) and experimental group (skin-glue with standard-securement) with study-instruments for primary outcomes (within 48 hours) and secondary outcomes (occlusion, site-infection, phlebitis/ dislodgement). They have given the findings based on the objectives with conclusions.
They have demonstrated their motivation for this study through an elaborate review of literature. According to the study, peripheral-IV catheters are inserted in nearly 80% of the hospitalized patients, with majority of the insertions in ED (Limm, 2013). Among which 33%- 69% of IV-devices fails prematurely due to infections, occlusions, phlebitis and/or dislodgement (Marsh, 2015a). This failure occurs mostly due to the improper fixation of peripheral-IV catheters in patient’s skin. Additionally, there is no clear evidence to show the best methods to secure peripheral-IV catheters. A newer method to improve the fixation of peripheral-IV catheter by using skin-glue (cyanoacrylate) at the insertion-site is employed in this study. Marsh (2015b) has stated the PIVC inserted in wards showed a reduction in failure-rate. The literatures quoted were current, relevant and comprehensive with correct reference citations. They could have included more evidences to describe about the failure rate of skin-glue and the effect of skin-glue in reducing occlusion, phlebitis and dislodgement as like infection. There are no studies to compare skin-glue method with current best comparators to generalize the results. They have conducted a single insertion-site, two-armed RCT in 360 adults with 380 peripheral-IV catheters in ED and were randomized by ‘Randomizers for clinical-trial software’ in 1:1 ratio; without blocking/stratifying to both standard-securement and skin-glue group. The skin-glue patients received one drop of cyanoacrylate-glue at the insertion-site and below the catheter’s hub. The standard care was carried-out based on Queensland- Departmental guidelines (2015) and measured the primary and secondary outcomes. They have stated the hypothesis as ‘the skin-glue application on the insertion-site of peripheral-IV catheters in ED would minimize the failure rate at 48 hours’ which is a scientific hypothesis that explains the expected relationship between variables (Polit, 2016). They have not given hypothesis for secondary outcomes. The hypothesis indicates that the researchers are interested in testing the relationships of application of skin-glue with catheter failure rate.
The sample was adequately described. In this study, the samples were selected by 1 of 3 research nurses (trained ED) in ED for 16 hours/day for a period of 7 days/week. They have selected patients those who requires hospital admission and are 18 or more years of age with patent peripheral-IV catheter inserted in upper-limb with intact skin and that is inserted by an ED nurse/physician and those gave written- informed consent. They have determined a sample size of 174 in each of two groups as standard care and skin-glue group. They have selected only the samples having one peripheral- IV catheter and have confirmed the peripheral- IV catheter’s patency by flushing 10-mL of 0.9% saline into it. They have excluded patients who are known case of allergic to skin glue or standard securement material, presence of infection, phlebitis or thrombosis near the catheter, agitated patients, non-English samples without interpreter.
The researchers have collected base- line demographic details as well as confounder (possible) details at the time of enrollment by using structured questionnaires with components as age, gender, intake of medications, number of PIVCs, insertion site, right or left upper- limb, professional who has inserted, PIVC gauge and hours from insertion to intervention and follow-up. The primary outcomes were measured in-person through direct visualization (for hospitalized patients) or through telephonic conversation (for discharged patients) at 48 hrs or more (Rickard, 2012, Webster, 2010). The authors have collected data for secondary outcomes through direct observation, chart- review as well as standardized client questionnaire. The data was collected by one of the three research nurses. The data are not described adequately. They have not mentioned the method of measuring study variables but they have described only the variables. For ex: they have described that they are measuring phlebitis but the method of measuring phlebitis (scores or rating scales) are not described. The authors have measured the data for primary outcomes through the demographic and confounder details in both standard-securement and skin-glue group and for secondary outcomes as infection, occlusions, dislodgment and phlebitis through direct observation, reviewing the client’s medical charts and standardized client’s questionnaire. The authors have not clearly explained about the origin of measurement instruments. They have just mentioned about the references from Rickard (2012) which suggests that they could have taken this reference as their guide and could have prepared the self-structured measurement instruments. They have not adequately described about their measurement instruments for both primary and secondary outcomes. The authors have only described about the questionnaire for measurement, but the method of measurement was not given. They have not validated the data collection instruments. The reliability of the measurement instruments were not assessed and reported. Ethical issues were not discussed except issues of follow-up.
The follow- up was complete enough to take the findings credible. Even the lower rate of follow-up loss (2.8% /PIVC and 0.83%/sample) that is similar in both the groups was managed by omitting the particular patients and only the patients with complete data were taken for analyses. They have not blinded the patients and staffs as it was impossible due to the subtle- color and appearance of skin- glue present at the time of intervention with follow-up. The research nurses were also not masked as they should allocate samples to skin- glue group and determine the integrity of intervention. There are significant differences (10%) (95% CI:–18% to –2% with p=.02) between the failure rate of peripheral- IV catheter in skin- glue group and standard group. Significant reduction (7%) in dislodgement (95% confidence- interval: –13% to 0% with p=.04) was noted in skin- glue group. Phlebitis & occlusion rates were also low in skin- glue but not statistically- significant. No infections are reported in both groups. The statistics used is inferential statistics which is used to draw inferences from given data to general conditions in which both p-values with point-estimation (CI) were used in this study (Polit, 2016, Newcombe, 2012). The statistical analysis of primary outcomes suggests that peripheral- IV catheter failure was lower in the skin- glue group as compared to standard- group at a confidence interval of 95% at p<.05 showing that there is a significant difference between both the groups and hence the statistical hypothesis is accepted (Polit, 2016). The analysis of secondary outcomes suggests that the difference between dislodgement of skin- glue group and standard- care group was statistically significant at a CI- 95% between –13% to 0% that showing increased significance difference between them p=.04 (p<.05). The difference between phlebitis in both groups is less with confidence- interval of 95% between –5 to 3% and occlusion with CI 95% of –8 to 4% shows that they are statistically significant. No evidence of infection in both groups (0%).
The findings of the study were expected. Enough information was presented to judge the results based on the objectives set by the researchers and have clearly and completely stated the results. The findings shows that the failure rate of PIVC was 10% lower in patients with skin-glue (17%) as compared to that of the standard group (27%) (Confidence interval 95%:–18% to –2%; p=.02) and the secondary outcome of PIVC failure due to dislodgement was noted to be 7% less in the skin- glue group (7.0%) than standard group (14%) (CI 95%:–13% to 0%). The failure rate of PIVC due to phlebitis as well as occlusion were found to be lowered in skin-glue group than standard group but were not statistically- significant. There are no infections in both the group. They stated that using IV lines with skin-glue are 5 times harder to fail. The individual patient analysis in standard (n=179) versus skin-glue group (n=170) shows that the PIVC failure rate was 52 and 31 and secondary failure rate was 51 and 28 respectively. The study was limited to only a particular area with local people-mix. They have not included the sclerotic drugs, anti-coagulants, potential confounders (no. of PIVC access, dwelling time) to generalize the results. The measurement of patient through telephones (n=209), might alter the results but the discharged samples were able to report complication (Rickard, 2012). PIVC failure tends to increase with dwelling time, which is not measured (Wallis, 2014). They suggested that they may proceed with cost-benefit analysis in the future, if financial needs are met. The researchers have mentioned the implications as use of skin-glue has reduced PIVC failure significantly (28%) and are simple and rapid method to carry-out in ED. There are no sufficient informations in this report to permit for replicating study.
The authors have concluded that the application of skin- glue in the PIVC insertion site along with the standardized care given by Queensland- Department of Health may minimize the rate of failure of peripheral- IV catheter in adult emergency department patients who are admitted in the hospital. The apparent reduction in the PIVC failure rate can benefit the patients by promoting comfort with outcomes and reduction of hospital admissions and costs that are caused due to complications. In 2016, Budgen found that the use of skin- glue that is made up of cyanoacrylates could make the peripheral- IV catheter lines harder and hence un-intentional removal and infection rate is reduced (HospiMedica, 2016). These findings suggest that use of skin- glue in PIVC will indirectly avoid interruption to therapy as well as prevent unnecessary anxiety and discomforts in re-inserting PIVC. Systemic sepsis that occurs in 0.1% of PIVC failure patients could also be prevented by this method (Stuart, 2013).
The nurses as the care takers should provide a quality nursing care to all the people at all the settings. The modern nurses have to be expertise in all the aspects of nursing care. The nurses should strive to conduct research and develop more evidences so as to enhance the nursing care by providing evidence based care to the patients. The most important role of the nurses involves preventing illness, protecting health as well as promoting health (ICN, 2010, ANA, 2010). As nurses form the primary care- giver in the emergency department of all the hospitals, they have to be expertise in various care modalities including care of peripheral- venous catheters and protect it from its premature failure and dislodgement of the catheter, infection at the catheter insertion skin site and occlusions of catheter due to blood clot or phlebitis (Rebelem, 2016).
Most of the patients admitted in the emergency department of hospitals are started with peripheral IV catheter line to start infusion and medicines so as to save the life of the patient among which 33% - 69% of IV- devices fails causing discomfort to the patients. The major predisposing factor to premature device failure involves the improper fixation of the peripheral- IV catheter to the limb of patient leading to not only dislodgement but also micro-motion resulting in irritation of vein leading to phlebitis and occlusion causing entry of micro- organisms from skin into the catheter entry- site leading to severe infection (Marsh, 2015a). This form of peripheral- IV catheter failure occurs mostly after 48 hours of insertion which implies that improvement has to be made for securement in this timeframe. Hence, nurses should secure the peripheral- IV catheter with some securement especially cyanoacrylates skin- glue near the catheter insertion site to create adherence of catheter with the patient’s skin so as to avoid premature failure. The nurses should conduct further research to use skin- glue to prevent failures in larger population to generalize the results. The CDC guidelines (2011) has designated that replacing intravenous catheters forms an unresolved care issue that indicates need for further research (O’Grady, 2011).
Peripheral- IV catheter failure causes disruption in therapies of patients such as hydration therapy, antibiotic and analgesic therapy resulting in the deterioration of patient’s heath adversely and interrupting the treatment process. This also indirectly burdens the patients and their family members by increasing the cost, producing anxiety with discomfort of re-inserting the catheter again and again (Aymes, 2016). Hence, nurses have to increase her expertise to secure the IV line safely so as to protect the patient’s values and protect their lives.
Further, it increases the costs of the health- care system of a country that includes increased nursing staff time in patient’s care, increased consumables, extended length of hospital stay with increased adverse- event managements. Even, a smaller reduction in the catheter- device failure will definitely transform in-to a larger improvements in patient’s care, health- outcomes and flow of health and treatment costs. Thus, by practicing skin- glue securing in patients with peripheral- IV catheter, the nurses will definitely improve the patient’s values and prevent subsequent morbidity, mortality, as well as reduces hospital charges (Stuart, 2013).
ANA. (2010). What is nursing?. Retrieved from https://www.nursingworld.org/Especially ForYou/StudentNurses/ What is nursingaspx
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/Callaham, M. L. (2017). Annals of Emergency Medicine: Official Journal of the American College of Emergency Physicians. Retrieved from https://www.journals.elsevier.com/annals-of-emergency-medicine
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 et al. (2015a). Devices and dressings to secure peripheral venous catheters to prevent complications [review]: Cochrane Database Syst Rev. 6:CD011070.
Marsh, N et al. (2015b). 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
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. EM. Retrieved from https://rebelem.com/should-we-use-skin-glue-to-secure-peripheral-ivs/
Rickard, C.M et al. (2012). Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomized controlled equivalence trial: Lancet. 380:1066-1074
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.University of South Australia. (n. d.). Critical Appraisal Tools. Retrieved from https://www.unisa.edu.au/Research/Sansom-Institute-for-Health-Research/Research/Allied-Health-Evidence/Resources/CAT/#Randomised
Wallis, M.C et al. (2014). Risk factors for peripheral intravenous catheter failure: a multivariate analysis of data from a randomized controlled trial: Infect Control Hosp Epidemiol.35: 63-68.
Webster, J et al. (2010). Clinically-indicated replacement versus routine replacement of peripheral venous catheters: Cochrane Database Syst Rev. 3: CD007798.
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